March 2018

ADVANCING OPTOMETRY

Glaucoma SUPPORTED BY Solving vision’s most puzzling disease Visual Field Tests CFEH’s Chair-side reference

CPD POINTS WITH PHARMA ONLINE Race to reduce IOP*

*Mean IOP reduction of up to 8.7 mmHg from baseline maintained over 24 hours with once daily dosing, over 3 months1

Travatan BAK-free contains POLYQUAD preservative2 POLYQUAD has minimal toxicity to mammalian cells.3 For patients with glaucoma, consider BAK-free medicines as an alternative treatment option when available.

IOP: Intraocular pressure; mmHg: Millimetres of mercury

PBS Information: This product is listed on the PBS for elevated intra-ocular pressure. Please review full Product Information before prescribing. For the most up to date Product Information go to http://www.novartis.com.au/products_healthcare.html TRAVATAN (travoprost 0.004%) Eye Drops. Indication(s): As first line monotherapy or adjunctive therapy to decrease elevated intraocular pressure in patients with ocular hypertension and/or open angle glaucoma. Dosage and administration: One drop in the conjunctival sac of the affected eye(s) each day. Shake the bottle well before use. Contraindications: Hypersensitivity to travoprost or any of the excipients in the medicine; pregnant women or women attempting to become pregnant. Precautions: Use with caution in aphakic patients, pseudophakic patients with torn posterior lens capsule or anterior chamber lenses, patients with known risk factors for macular oedema. No experience in in inflammatory ocular conditions, inflammatory, neovascular, angle closure or congenital glaucoma and only limited experience in open angle glaucoma of pseudophakic patients and in pigmentary glaucoma. Therefore, use with caution in patients with active intraocular inflammation and/or predisposing risk factors for iritis/uveitis. Patients should be informed about possible changes to eye colour, eyelash thickness and/or length and periorbital and/or eyelid skin darkening. Patients who continue to wear soft contact lenses must be instructed to remove contact lenses prior to administration and wait 15 minutes after instillation of the dose before reinsertion. Use in paediatric patients has not been established. Use in pregnancy: Category B3. Use in lactation: there is no data on excretion into human milk, patients should stop breastfeeding. May cause transient blurred vision following instillation, which may impair the ability to drive or operate machinery. Interactions with Other Medicines: Drug-drug interactions involving protein binding are unlikely; Concomitant therapy with miotics or adrenergic agonists has not been evaluated. Adverse Effects: Very common (≥10%): conjunctival hyperaemia, ocular hyperaemia, iris hyperpigmentation. Common (1 to <10%): punctate keratitis, anterior chamber cell, anterior chamber flare, eye pain, photophobia, eye discharge, ocular discomfort, eye irritation, abnormal sensation in eye, foreign body sensation in eyes, visual acuity reduced, vision blurred, dry eye, eye pruritus, lacrimation increased, erythaema of eyelid, eyelid oedema, eyelids pruritis, growth of eyelashes, eyelash discolouration, headache, skin hyperpigmentation (periocular), skin discolouration. Less frequent adverse effects are listed in the full Product Information. (tra040717m based on tra040717i). For medical enquiries please contact 1800 671 203 (phone) or medinfo.phauno@novartis. com (email) REFERENCES: 1. Gandolfi S et al. Eur J Ophthalmol 2012; 22(1): 33–44. 2. Travatan (travoprost 0.004%) Eye Drops Product Information. 4 July 2017. 3. Rolando M et al. Expert Opinion on Drug Deliv 2011; 8(11):1425–1438. ®Registered trade mark. Novartis Pharmaceuticals Australia, 54 Waterloo Road, Macquarie Park, NSW 2113. AU-4682 Date of preparation: February 2018. NOGL13153W.

NOGL13153W Travatan Full Page Ad_V4b_FA.indd 1 1/02/2018 4:41 PM March 2018

This issue of Pharma is supported by

Editor JEFF MEGAHAN 02 13

Clinical Editor Introduction to the Visual Fields: past present Associate Professor Mark Roth glaucoma issue and future BSc(Pharm) BAppSc(Optom) Jack Phu PGCertOcTher NEWENCO FAAO OAM 03 Sleep apnoea and POAG 14 Cover design Dr Victor Liu and FEATURE Laura Gulbin Dr J James Thimons Chair-side Reference: Optometry Australia Visual Field Tests ABN 17 004 622 431 05 Michael Yapp / Centre for Eye Health Level 1, 201 Clarendon Street Monitoring glaucoma 23 South Melbourne VIC 3205 patients Ph 03 9668 8500 Infantile nystagmus Beata I Lewandowska Fax 03 9663 7478 syndrome Leah Batterham [email protected] www.optometry.org.au 08 Selective laser 25 Copyright © 2018 trabeculoplasty for open Floaters: a clinical and angle glaucoma Comments made in Pharma are of surgical update a general nature and intended for Dr Jessica Steen guidance only. Optometry Australia and Dr Simon Chen the individual contributors expressly disclaim all liability and responsibility and Dr Chris Hodge to any person in respect of, and for the 11 consequences of, anything done or omitted to be done in reliance wholly or An overview of optical partly on anything in this publication. coherence tomography 21 Pharma is distributed in Australia angiography (OCT-A) and New Zealand. All references to Dr Rim Makhlouf Therapeutic News of note pharmaceutical preparations in Pharma are applicable within Australia. Associate Professor Mark Roth 2 MARCH 2018

This issue of Pharma is supported by Novartis Pharmaceuticals Australia

Novartis draws on a long history of advancing science in the interest of better health. Today, we continue to build on this heritage, focusing on the unmet needs of patients worldwide. As most healthcare providers already know, many of these needs are the result of a growing, ageing population—a significant proportion of which will develop glaucoma. Healthcare professionals will need to develop new strategies to meet the ever-increasing challenge of confronting glaucoma world-wide. The impact on the lives of those with glaucoma is hard to overstate. Effective diagnosis and treatment for at-risk patients is the key to preventing blindness from glaucoma. Because it is often asymptomatic and undetected, optometrists play a crucial role in the identification, treatment and support of those with glaucoma. Early detection remains the vital first step in a sequence of measures that prevents the progression of nerve damage. Novartis is proud to support Pharma in its ongoing efforts to inform the prac- ticing optometrists of Australia and New Zealand of innovations in the growing areas of healthcare. Through our shared commitment, we hope to increase early detection and suitable treatment options that will ultimately yield the best patient outcomes.

Glaucoma Care and the Future Optometry Australia presents a live and informative evening webcast

When: Tuesday, 10 April 2018 Speakers: Dr. Andrew White and Mr. Jack Phu

Learn how to accurately read an OCT and what the future of glaucoma care looks like with neuroprotection.

This webcast offers up to 4.5T CPD points

Proudly sponsored by For more information contact: Optometry Australia Email: [email protected] www.optometry.org.au MARCH 2018 3

Sleep apnoea and POAG Continuous positive airways pressure Dr Victor Liu OD treatment and elevated IOP

The University of Melbourne Optometry and Vision Sciences at a four times higher risk of developing was 6/6 in each eye. The patient had POAG compared to Caucasians.4 significant bilateral floppy eyelids, and Dr. J. James Thimons pupils revealed a Marcus Gunn afferent OD FAAO ABO IOP remains the only modifiable defect in the left eye (LE). Anterior risk factor in preventing or delaying chamber angles were open (ciliary 9 Medical Director, Ophthalmic glaucoma progression. As primary body 360 degree in each eye using Consultants of Connecticut, USA eye care providers, it is important to gonioscopy). CCT measurements were maintain a consistent management plan within normal limits (RE 560µm, LE appropriate in achieving target IOP 552µm). IOP measurements at 5:00pm levels. With advances in technology, by Goldmann applanation tonometry research, surgery and pharmacological were 20 mmHg in the RE and 23 mmHg Primary open angle glaucoma (POAG) agents, we are developing better means in the LE. No pseudoexfoliation or is the most common form of glaucoma, of providing care for our patients. cataract was observed in either eye. accounting for more than 90 per cent Dilated fundus examination (DFE) of the cases.1 An individual’s chance of showed a healthy right optic nerve (C/D developing POAG increases based on CASE REPORT ratio 0.4) and abnormal left optic nerve several risk factors including: elevated with superior erosion, laminar pores intraocular pressures (IOP), central and superior optic pit. corneal thickness (CCT), age, family TM, a 48-year-old African-American ocular history, gender, myopia, certain male, was first referred in 2012 for a DFE findings were confirmed with systemic diseases and ethnicity.2-5 glaucoma diagnosis. He had a complex optical coherence tomography (OCT) medical history of significant hearing and automated perimetry using a Studies have confirmed a higher loss and sleep dysfunction. He was Humphrey Field Analyzer (HFA). The prevalence of POAG in people of currently taking Motrin and Flexeril for right eye was normal in both tests. The African descent between the ages of previous medical injuries. TM also has left eye OCT confirmed a superior RNFL 40–80 years old compared to any other a family history of glaucoma. loss at the disc in the left eye and HFA ethnicity.4,6-8 The Baltimore Eye Survey found a significant inferior macular Report found African-Americans to be On examination, unaided visual acuity bundle defect (Figures 1 and 2).

Continued page 4

Figure 1. OCT confirms superior RNFL loss at Figure 2. Humphrey Field Analyzer shows significant inferior macular bundle defect in left eye the disc in the left eye. (Image: Dr J. James Thimons, (Image: Dr J. James Thimons, OD, FAAO) OD, FAAO) 4 MARCH 2018

NAAION as a differential diagnosis to production and increases uveoscleral CPAP glaucoma.12,13 outflow during the day. On the other hand, its nocturnal profile was not From page 3 In a report, patients with sleep apnoea sufficient in maintaining low IOP, and currently undergoing CPAP thus a carbonic anhydrase inhibitor have demonstrated an associated (CAI) such as Brinzolamide is a great TM was placed on Alphagan P 1 drops increase in IOP, especially at night.14 additive in controlling nocturnal IOP twice a day and referred for a full blood The mechanism of CPAP on raised fluctuations.18 workup to rule out the possibility of IOP is not well understood, but vascular insult. He was also referred to theories hypothesise an elevated Studies were conducted in order to a sleep study for further investigation of CPAP intrathoracic pressure may evaluate the efficacy of lowering IOP suspected undiagnosed sleep apnoea. cause a rise in venous circulation using brinzolamide/brimonidine pressure, thus reducing the outflow of fixed-combination (BBFC) therapy. The aqueous through the episcleral veins.14 results found that this combination FOLLOW-UP Normally, aqueous humour production was significantly superior in its IOP- TM was diagnosed in late 2012 with at night decreases, but there is an lowering activity 20–35 per cent from severe sleep apnoea during REM increase in episcleral venous pressure baseline and had a consistent safety sleep with oxygen desaturation. He due to lying in the supine position.15 profile compared to its individual was recommended to commence They found a significant drop in IOP components.19-22 Continuous Positive Airways was observed when CPAP was ceased Pressure (CPAP) treatment and pursue for 30 minutes. This is important as it In 2016, a six-week, randomised, weight loss to achieve an ideal body was found that diurnal IOP variation double-masked, study investigated weight. TM was on a three-month is linked to significant visual field loss. the additive effect of Simbrinza as an review schedule for one year at our It has been reported that there is a 30 adjunct to PGA. They found at two clinic to closely monitor his IOP per cent chance of visual field loss with hours post-instillation, BBFC reduced fluctuations and evaluate the efficacy every 1 mmHg increase over a five-year a mean IOP of 7.1 mmHg (31 per cent) of monotherapy drops via fundus, IOP, increment.16 from PGA baseline.23 A potential OCT and VF tests. limitation to this study was that the Monotherapy is not always sufficient degree of reduced IOP was evaluated In 2013 TM’s IOP was unstable and in managing and maintaining a target based upon the eye with the highest fluctuated at each of his six-month IOP and/or preventing glaucoma baseline IOP. Future studies with longer reviews. In an effort to lower his IOP, progression. According to the Ocular duration may provide supplementary the therapeutic drops were changed Hypertensive Treatment Study information regarding the efficacy of three times trialling Travatan, Asopt (OHTS), 40 per cent of patients require adjunct therapy of BBFC+PGA. and Combigan, respectively. All of a second ocular hypotensive eye which proved to be insufficient in drop in order to achieve a targeted As with all therapeutic management, maintaining a low target IOP. reduction of 20 per cent.17 Benefits proper precautions and contraindications of fixed-drop combination therapies should be exercised before prescribing It wasn’t until 2014 that TM was include increased likelihood of patient Simbrinza to your patient. prescribed Simbrinza suspension (three compliance, reduced exposure to a day) that his IOP dropped within preservatives and less chances of 1. Quigley HA, Broman AT. The number 11 of people with glaucoma worldwide target range and maintained stable sequential medication washout. in 2010 and 2020. British Journal of pressures. To this day, he maintains However, until recently, beta-blockers Ophthalmology 2006; 90: 262-267. a healthy target IOP and is still (particularly timolol 0.5%) were 2. Allingham RR, Liu Y, Rhee DJ. The genetics of primary open-angle undergoing treatment for his severe the most commonly-used agent in glaucoma: a review. Experimental Eye sleep apnoea. fixed-combination eye drops. Due to Research 2009; 88: 837-844. local allergy or systemic side effects 3. Wolfs RC, et al. Genetic risk of primary open-angle glaucoma: population-based associated with use of beta-blockers, DISCUSSION familial aggregation study. Archives of these drugs have been contraindicated Ophthalmology 1998; 116: 1640-1645. 4. Tielsch JM, et al. Racial variations in Sleep apnoea is a common chronic in many patients with cardiac issues. the prevalence of primary open-angle disorder and requires life-long care. It Not recommended for first line glaucoma: the Baltimore Eye Survey. has been found to be more prevalent treatment, fixed-combination eye drops Jama 1991; 266: 369-374. 10 5. Coleman AL, et al. Baseline risk in males than females. It has also are mainly used if a prostaglandin factors for the development of primary been documented previously to be analogue (PGA) or other agent is open-angle glaucoma in the Ocular associated with ocular diseases such unsuccessful in lowering IOP, and can Hypertension Treatment Study. Am J Ophthalmol 2004; 138: 684-685. as glaucoma, non-arteritic anterior be useful additives in achieving target 6. Leske MC. The epidemiology of open- ischaemic optic neuropathy (NAAION), IOP. angle glaucoma: a review. American bilateral disc oedema, floppy eyelid Journal of Epidemiology 1983; 118: 166- 191. syndrome, blepharitis, ptosis, papillary Simbrinza suspension is an effective 7. Leske MC, et al. Risk factors for incident conjunctivitis, filamentary keratitis, fixed-combination eye drop that is open-angle glaucoma: the Barbados Eye retinal vascular tortuosity and also the only fixed-combination agent Studies. Ophthalmology 2008; 115: 85- 11 93. central serous chorioretinopathy. that does not contain timolol 0.5%. 8. Tham YC, et al. Global prevalence Previous studies have shown a strong It comprises of brinzolamide 1% and of glaucoma and projections of implication of sleep apnoea with brimonidine tartrate 0.2%. Brimonidine glaucoma burden through 2040: a systematic review and meta-analysis. NAAION, thus it is important to is a selective alpha-2-adrenergic Ophthalmology 2014; 121: 2081-2090. consider and rule out suspicions of agonist that acutely reduces aqueous 9. Coleman AL, Miglior S. Risk factors for MARCH 2018 5

glaucoma onset and progression. Survey of Ophthalmology 2008; 53: S3-S10. 10. Young T, et al. The occurrence of Monitoring glaucoma sleep-disordered breathing among middle-aged adults. New England Journal of Medicine 1993; 328: 1230- 1235. patients 11. Waller EA, Bendel RE, Kaplan J, Sleep disorders and the eye. Mayo Clinic Proceedings 2008; 83: 1251- 1261. 12. Mojon DS, et al. Association Did a patient’s past drug use lead to between sleep apnea syndrome and nonarteritic anterior ischemic optic neuropathy. Archives of current troubles? Ophthalmology 2002; 120: 601-605. 13. Mojon DS, et al. Primary open-angle glaucoma is associated with sleep apnea syndrome. Ophthalmologica diagnosed with glaucoma in both eyes. 2000; 214: 115-118. He reported the intraocular pressure 14. Kiekens S, et al. Continuous positive Beata I Lewandowska (IOP) at the time of diagnosis was 25 airway pressure therapy is associated OD with an increase in intraocular mmHg in the right eye. He had been pressure in obstructive sleep apnea. using Travatan Z every bedtime in Investigative Ophthalmology & Diplomate, American Board Visual Science 2008; 49: 934-940. both eyes since the diagnosis and was 15. Prata TS, et al. Posture-induced of Optometry started on Combigan twice a day in the intraocular pressure changes: right eye about a month prior to his considerations regarding body position in glaucoma patients. Survey Assistant Professor current visit. of Ophthalmology 2010; 55: 445-453. Nova Southeastern University 16. Nouri-Mahdavi KH, et al. College of Optometry, Florida, USA The patient admitted to poor Comparison of methods to predict visual field progression in glaucoma. compliance with topical medications. Archives of Ophthalmology 2007; He denied any history of trauma or 125: 6. 17. Kass MA, et al. The Ocular ophthalmic surgery. The patient’s Hypertension Treatment Study: medical history revealed a Mallory- a randomized trial determines CASE REPORT Weiss tear that had been surgically that topical ocular hypotensive medication delays or prevents repaired in 1985. He also reported the onset of primary open- taking steroids for bodybuilding for angle glaucoma. Archives of A 58-year-old Caucasian male about a year more than 20 years ago. Ophthalmology 2002; 120: 701-713. 18. Fan S, et al. Daytime and nighttime presented complaining of progressively The patient was taking 20 mg of the effects of brimonidine on IOP decreased, dim, tunnel-like vision oral medication Omeprazole every day and aqueous humor dynamics and colour abnormalities in the right for high cholesterol. Family history was in participants with ocular hypertension. Journal of Glaucoma eye. He had noticed the symptoms positive for glaucoma of unknown type 2014; 23: 276. worsening over the previous six in the patient’s grandmother. It was not 19. Katz G, et al. Three-month months. Past ocular history revealed known whether she had gone blind. randomized trial of fixed- combination brinzolamide, 1%, that a year prior to the visit, he had and brimonidine, 0.2%. JAMA had his first eye examination and was Continued page 6 Ophthalmology 2013; 131: 724-730. 20. Nguyen QH, et al. Phase 3 randomized 3-month trial with an ongoing 3-month safety extension of fixed-combination brinzolamide 1%/ brimonidine 0.2%. Journal of Ocular Pharmacology and Therapeutics 2013; 29: 290-297. 21. Aung T, et al. Twice-daily brinzolamide/brimonidine fixed combination versus brinzolamide or brimonidine in open-angle glaucoma or ocular hypertension. Ophthalmology 2014; 121: 2348- 2355. 22. Gandolfi SA, et al. Randomized trial of brinzolamide/brimonidine versus brinzolamide plus brimonidine for open-angle glaucoma or ocular hypertension. Advances in therapy 2014; 31: 1213-1227. 23. Fechtner R, et al. Ocular hypotensive effect of fixed-combination brinzolamide/brimonidine adjunctive to a prostaglandin analog: a randomized clinical trial. Eye 2016; 30: 1343-1350.

Figure 1. Visual field test revealing superior and inferior visual field defects in the right eye. 6 MARCH 2018

Glaucoma patients From page 5

The patient denied suffering from allergies to any medications. He denied smoking, stated he occasionally drank beer, and reported consuming two cups of coffee per day. The patient’s mood and affect were normal and he was oriented to person, place and time. The patient’s blood pressure was measured at 153/90 at 2:13 pm.

Uncorrected distance visual acuities were 6/6-2 in the right eye and 6/6 in the left eye. Pupils were equal, round and reactive to light without an afferent pupillary defect in either eye. Ocular Figures 2A and 2B. Colour optic nerve photos demonstrating cupping in the right eye (2B). motility was normal in both eyes. Note the advanced neuroretinal rim tissue thinning in the inferior, infero-temporal and temporal regions as part of temporal unfolding in the right eye. Note the temporal loss of RPE in the beta Colour vision testing revealed a blue- zone and mild hypo- and hyper-pigmentation changes in alpha zone of the right eye. Bayonet- yellow defect in the right eye, but was ing of the vein can be observed at the inferior disc edge of the right eye. normal in the left eye. Humphrey Field Analyzer was reliable in both eyes and revealed a dense superior arcuate scotoma and inferior nasal field defect margins. Conjunctiva exhibited mild and without any transillumination in the right eye (Figure 1). hyperaemia in both eyes and there defects in either eye. Lenses were was an early pinguecula present clear in both eyes and there was no Slitlamp examination of the anterior temporally in the right eye. Cornea pseudoexfoliation of the lens capsule segment revealed mild dermatochalasis was clear in both eyes; neither keratic in either eye. IOP was 19 mmHg in of both upper eyelids. There was precipitates nor Krukenberg’s spindles both eyes measured by applanation no proptosis observed in either were observed in either eye. Anterior tonometry at 2:50 pm. eye. Meibomian gland capping was chamber was deep and quiet in both observed in both eyes with quiet lid eyes. Iris was flat and intact, brown Gonioscopy revealed ciliary body band

Figures 3A and 3B. OCT demonstrating RNFL and GCL loss in the right eye MARCH 2018 7

360 degrees in both eyes with regular Corticosteroids Androgenic-anabolic steroids approach and 1+ trabecular meshwork What are they? Closely related to cortisol, a hormone which Synthetic derivatives of the male hormone is naturally produced in the outer layer of testosterone pigmentation in both eyes. There was the adrenal glands no peripheral anterior synechiae, no How do they function? Act on the immune system producing Promote the growth of skeletal muscle recession, no neovascularisation and anti-inflammatory, immunosuppressive (anabolic effect) no blood present in Schlemm’s canal and anti-mitogenic effects by stimulating production of lipocortin which inhibits the Promote the development of male sexual in either eye. Dilated retinal fundus activity of phospholipase A2 characteristics (androgenic effects) examination revealed a clear vitreous When are they prescribed? Treatment of autoimmune and inflammatory Treatment of conditions that occur due to in both eyes. The optic nerve was conditions (vasculitis, rheumatoid arthritis, testosterone deficiency (delayed puberty, pink and distinct in both eyes with lupus, gout, myositis, Sjögren’s syndrome) certain types of impotence) advanced cupping and extensive Systemic side-effects5,6 • reduction in bone formation and increase • increase in sexual drive peripapillary atrophy observed in the bone resorption • acne vulgaris right eye (Figures 2A and 2B). • reduction in serum sex hormone levels • increase in body hair • hypercalciuria • aggressive behavior The cup-to-disc ratio was estimated • myopathy • mood disturbances to be 0.90/0.95 in the right eye • increased serum lipids • hypertension and 0.50/0.55 in the left eye. Disc • hyperglycaemia • lower serum HDL, HDL2 and HDL3 choles- • hypertension terol levels haemorrhages were not observed in • gastritis either eye. Maculae were flat and dry • peptic ulceration with few small drusen in the foveal • psychiatric disorders region of both eyes. Vessels were normal in both eyes. Retinal periphery was flat 2,7 and intact 360 degrees in both eyes. Ocular side-effects • cataracts Improvement in lipid production by the • increased IOP meibomian glands • central serous chorioretinopathy Central corneal thickness was • papilloedema measured at 601 μm in the right eye and 605 μm in the left. Optical coherence tomography (OCT) was Table 1. Comparison of corticosteroids and androgenic-anabolic and their common side-effects reliable and revealed retinal nerve fibre layer (RNFL) thinning and retinal ganglion cell (RGC) loss in the right eye (Figures 3A and 3B). corticosteroids is known to cause 1. Agarwal R, Gupta SK, Agarwal P, et al. significant increase in IOP, which Current concepts in the pathophysiology of glaucoma. Indian J Ophthalmol 2009; We concurred with the patient’s may lead to open angle glaucoma.2 57: 257–266. previous diagnosis of primary open It is believed that corticosteroid use 2. Poetker DM, Reh DD. A comprehensive review of the adverse effects of systemic angle glaucoma in the right eye. Given increases outflow resistance of the corticosteroids. Otolaryngol Clin North the patient’s age, good systemic health aqueous by inhibiting the degradation Am 2010; 43: 753–768. and advanced field loss in the right of extracellular matrix material in the 3. Kersey JP, Broadway DC. Corticosteroid- 3 induced glaucoma: a review of the eye, we set the target IOP in the right trabecular meshwork. literature. Eye (Lond). 2006; 20: eye in the low teens. We advised 407–416. the patient to continue instilling Early detection and treatment of 4. Heijl A, Leske MC, Bengtsson B, et al. 4 Reduction of intraocular pressure and Combigan twice a day in the right eye glaucoma leads to slower progression; glaucoma progression: results from the and Travatan Z in both eyes at bedtime however, our patient’s history revealed Early Manifest Glaucoma Trial. Arch and to start Dorzolamide twice a day he used steroids for bodybuilding. Ophthalmol 2002; 120: 1268–1279. 5. Hartgens F, Kuipers H. Effects of in the right eye. We discussed our These substances belong to the androgenic-anabolic steroids in athletes. findings with the patient, stressing the androgenic-anabolic (AAS) derivatives Sports Med 2004; 34: 513–554. progressive nature of glaucoma and group.5 It is unlikely they contributed 6. Moghadam-Kia S, Werth VP. Prevention and treatment of systemic glucocorticoid the importance of his compliance with to the development of glaucoma in side effects. Int J Dermatol 2010; 49: the prescribed treatment and regular the right eye. While AAS misuse has 239–248. follow-up examinations. In light of been associated with disturbance of 7. Sullivan DA, Sullivan BD, Evans JE, et al. Androgen deficiency, meibomian the patient’s previous struggles with endocrine, immune, cardiovascular, gland dysfunction, and evaporative compliance, we referred him to a urogenital and psychiatric function,6 dry eye. Ann N Y Acad Sci 2002; 966: glaucoma specialist for continuation the literature does not reveal any 211–222. 8. Wickham LA, Gao J, Toda I, et al. of care. reports of adverse ophthalmic side- Identification of androgen, estrogen and effects. On the contrary, studies have progesterone receptor mRNAs in the shown that women suffering from eye. Acta Ophthalmol Scand 2000; 78: DISCUSSION 146–153. primary and secondary Sjögren’s 9. Colligris B, Alkozi HA, Pintor J. Glaucoma is a heterogeneous group syndrome are androgen-deficient.7 Recent developments on dry eye disease treatment compounds. Saudi J of diseases with multiple primary There is evidence that the androgen Ophthalmol 2014; 28: 19–30. and secondary factors that lead to deficiency may lead to meibomian irreversible vision loss from the gland dysfunction, altered lipid dysfunction and death of retinal profiles in meibomian gland ganglion cells (RGC).1 Elevated IOP secretions, tear film instability, and is considered to be one of the initial evaporative dry eye.7,8 Androgen causes of insult in glaucomatous receptor modulators are being studied atrophy.1 Prolonged treatment with for treatment of dry eye disease.9 8 MARCH 2018

Selective laser trabeculoplasty for open angle glaucoma SLT has emerged as a viable first-line treatment option

moderate cases, the goal of treatment meshwork.2,10 Although smaller areas, of open angle glaucoma is not to (180 degrees) of trabecular meshwork Dr Jessica Steen improve vision, but rather to slow may be treated, the current trend OD FAAO or prevent vision loss.2 With up to is to treat 360 degrees of trabecular half of patients not adherent with meshwork unless significant risk Optometric Physician glaucoma medications 75 per cent of factors for complications such as the time, adherence is a major barrier to a heavily pigmented trabecular Diplomate, American Board treatment success.8 meshwork exist.2,6,7 of Optometry Cost of medication, forgetfulness, The mechanism of action by which Nova Southeastern University hand tremor, limited understanding SLT lowers IOP is not completely College of Optometry, Florida, USA of the permanently blinding nature understood. It is generally accepted of the disease and the side-effect that laser energy selectively targets profile of topical medications are and stimulates melanocytes in the also barriers to adherence with trabecular meshwork, which results topical medication use.5,8 Ocular in recruitment of macrophages and Treatment of open angle glaucoma side-effects of medical treatment monocytes from the spleen to the (OAG) typically follows the standard range from mild to intolerable and trabecular meshwork. procedure of initial therapy with topical include redness, ocular surface disease intraocular pressure (IOP) lowering and cosmetic changes including These monocytes and macrophages medications, followed by laser surgery pseudo-enophthalmos and periorbital phagocytose trabecular meshwork including selective laser trabeculoplasty darkening.5,8 Systemic side-effects debris, ultimately lead to reduced (SLT) and finally, incisional surgery if range from mild to life threatening resistance to aqueous outflow.2,3,6,11 The other measures fail.1-3 and may significantly detract from the expression of inflammatory cytokines patient’s quality of life.5,8 may lead to remodeling of the Surgical procedures are classically juxtacanalicular extracellular matrix, reducing aqueous outflow resistance reserved for patients who have had SLT indications disease progression with maximally through a cellular mechanism.12 tolerated medication use.2,3 With SLT is used to lower IOP in the widespread use of ancillary diagnostic treatment of OAG and ocular A precursor to SLT, argon laser technology, earlier diagnosis of hypertension including primary open trabeculoplasty (ALT) was the first open angle glaucoma often involves angle glaucoma (POAG), pigmentary laser procedure evaluated as a first- initiation of medical treatment at glaucoma, pseudo-exfoliative line treatment in OAG.13 ALT lowers a younger age.4 As patients require glaucoma, steroid-induced glaucoma, IOP through thermal stimulation and lifelong therapy, earlier treatment with and retinal detachment repair requiring scarring of the trabecular meshwork, topical therapy increases the potential silicone oil.2,3 which results in mechanical for medication failure and intolerable opening and increased outflow of side-effects during a lifetime.2 Treatment of OAG with SLT areas adjacent to treated trabecular decreases necessity of adherence with meshwork.14 With known patient challenges medications and may prolong the with adherence to topical ocular need of further intervention including The Glaucoma Laser Trial (GLT) medications, alternative options for additional medications or incisional evaluated the efficacy of ALT first-line therapy including SLT, which surgery.1-3 SLT may have a positive compared to topical medications and does not rely on patient adherence, impact on quality of life in patients determined that ALT was at least as have been evaluated.1,2,5-7 SLT has with glaucoma.9 It is an alternative effective as topical medications in gained notoriety as a viable first-line treatment to be considered for pregnant lowering IOP; however, this study was therapy in patients with OAG. patients, which can be performed performed prior to the availability of in all three trimesters, and may be prostaglandins.13 As a result of the used as first-line therapy or to reduce permanent scarring of the trabecular Challenges with topical medications the number of medications during meshwork, repeat treatment is not Although generally safe and effective, pregnancy.2,4 considered to be effective.3,6 medical treatment of elevated In contrast to ALT, SLT uses a very intraocular pressure has significant How SLT works patient barriers to success, such as short pulse duration, which does patient adherence with prescribed SLT utilises a Q-switched, frequency- not cause permanent destruction or treatment.5,8 As a chronic asymptomatic doubled, 532 nm Nd:YAG laser scarring of surrounding tissues.2,3 disease, especially in early and directed towards the trabecular SLT uses lower energy levels in MARCH 2018 9

Selective laser trabeculoplasty for open angle glaucoma

shorter pulses over a larger area and is comparable to ALT in terms of efficacy and safety.14,15 Less pain and inflammation are often described following SLT compared to ALT, which is likely to be due to the less than one per cent total energy applied with SLT.16

Success of SLT SLT is effective in lowering IOP but not all patients will respond to treatment.1-3,10 Response rate ranges from 40 per cent to 82 per cent, depending on the definition of success.2,3,10,17 The IOP-lowering response of one eye can be used Figure 1. Aiming helium-neon (HeNe) laser beam of the SLT device focused on to predict whether the fellow eye the trabecular meshwork Image: Dr Neal Whittle will have a positive response to treatment.18 SLT has also been shown to be effective in dampening IOP fluctuations and achieving IOP stability during a 24-hour period when the trabecular meshwork is treated 360 degrees.17,19 However, travoprost is more effective in IOP dampening during daytime hours than SLT.19

SLT efficacy decreases with time.2,3 Treatment typically lasts between one and five years with an average of approximately two years.1,2,6,7,15 Due to the lack of permanent trabecular meshwork damage following primary SLT, the procedure may be repeated.6,20 Repeat SLT results in comparable levels of IOP-lowering following initial treatment. (That is: repeat SLT Figure 2. HeNe laser beam focused on lightly pigmented trabecular meshwork can re-establish the IOP achieved after Image: Dr Neal Whittle primary treatment).6,15,20

There has been no correlation of IOP- lowering success with SLT with age or sex.21 Concurrent treatment with IOP lowering medications does not impact the efficacy of SLT.22 The most widely-accepted factor influencing a greater IOP-lowering effect is a higher pre-treatment IOP.21 However, SLT may be used successfully in patients with open angle glaucoma with statistically normal pressures, often termed normal tension glaucoma (NTG).21 Although SLT targets melanocytes, the amount of trabecular meshwork pigmentation and type of OAG have not been shown to predict IOP-lowering response.21

Figure 3. HeNe laser beam focused on the trabecular meshwork in a patient with minimal pigmentation Image: Dr Neal Whittle Continued page 10 10 MARCH 2018

Transient corneal haze and temporary V. Quality of life in glaucoma patients decreased endothelial cell count may after selective laser trabeculoplasty. Int J SLT Ophthalmol 2017; 10: 742–748. occur hours after the procedure with 10. Latina MA, Sibayan SA, Shin DH, From page 9 full resolution within one month et al. Q-switched 532-nm Nd:YAG 2 laser trabeculoplasty (selective laser without treatment. trabeculoplasty):a multicenter, pilot, clinical study. Ophthalmology 1998; 105: 2082–2088; discussion 2089–2090. SLT as a first line treatment Bottom line 11. Gulati V, Fan S, Gardner BJ, et al. Mechanism of action of selective laser Classically, laser and incisional surgery SLT is safe and effective, with generally trabeculoplasty and predictors of are reserved for cases of inadequate transient mild side-effects. Its efficacy response. Invest Ophthalmol Vis Sci 2017; 58: 1462–1468. IOP with maximally-tolerated topical is comparable to a prostaglandin 12. Skaat A, Rosman MS, Chien JL, et therapy. SLT with treatment 360 analogue for about a two-year period as al. Microarchitecture of Schlemm degrees has been shown to be as a first-line therapy and once treatment canal before and after selective laser trabeculoplasty in enhanced depth effective as a topical prostaglandin wears off, SLT may be repeated. Many imaging optical coherence tomography. J analogue in lowering IOP in patients glaucoma patients require more than Glaucoma 2017; 26: 361–366. with OAG as a first line treatment.1,7,15 one medication to control IOP during 13. The Glaucoma Laser Trial (GLT) and glaucoma laser trial follow-up study: 7. their lifetime. Results. Glaucoma Laser Trial Research Group. Am J Ophthalmol 1995; 120: Complications of SLT Although SLT is not a permanent cure 718–731. 14. Kent SS, Hutnik CM, Birt CM, et al. A Side-effects experienced after SLT are for the disease, it may allow for the randomized clinical trial of selective generally mild and temporary, and reduction in the number of topical laser trabeculoplasty versus argon can be managed with topical medical medications or delay the addition laser trabeculoplasty in patients with pseudoexfoliation. J Glaucoma 2015; 24: measures.10,15 The most common of IOP-lowering medication. Using 344–347. side-effects after SLT are transient IOP SLT as a first-line therapy in the 15. Wong MO, Lee JW, Choy BN, et al. Systematic review and meta-analysis elevation, anterior chamber reaction, treatment of OAG eliminates patient on the efficacy of selective laser redness and discomfort.10,15,23,24 medication side-effects and drug costs trabeculoplasty in open-angle glaucoma. while averting the dilemma of patient Surv Ophthalmol 2015; 60: 36–50. 16. Martinez-de-la-Casa JM, Garcia-Feijoo J, Post-operative inflammation typically adherence required for treatment Castillo A, et al. Selective vs argon laser occurs two-to-three days following success. Despite a growing body of trabeculoplasty: hypotensive efficacy, SLT and resolves in about five days supportive evidence that establishes anterior chamber inflammation, and 23 postoperative pain. Eye (Lond) 2004; 18: without treatment. The use of post- the efficacy and safety of SLT as a first- 498–502. operative steroid or nonsteroidal line treatment in open angle glaucoma, 17. Nagar M, Luhishi E, Shah N. Intraocular anti-inflammatory drugs (NSAIDs) its use in clinical practice remains pressure control and fluctuation: the effect of treatment with selective laser is generally not recommended in limited. trabeculoplasty. Br J Ophthalmol 2009; patients who have undergone SLT, 93: 497–501. due to its presumed mechanism of 18. Lee JW, Wong MO, Wong RL, et al. 1. Freitas AL, Ushida M, Almeida I, et al. Correlation of intraocular pressure action, which relies on recruitment between both eyes after bilateral 23 Selective laser trabeculoplasty as an of inflammatory cells. However, initial treatment option for open-angle selective laser trabeculoplasty in open- the use of post-operative NSAIDs or glaucoma. Arq Bras Oftalmol 2016; 79: angle glaucoma. J Glaucoma 2016; 25: e248–e52. steroid topical medication has not 417–421. 2. Prum BE Jr, Rosenberg LF, Gedde SJ, 19. Kiddee W, Atthavuttisilp S. The effects been shown to reduce the efficacy of et al. Primary open-angle glaucoma of selective laser trabeculoplasty and treatment following SLT.23 preferred practice pattern guidelines. travoprost on circadian intraocular Ophthalmology 2016; 123: 41–111. pressure fluctuations: A randomized 3. Samples JR, Singh K, Lin SC, et al. clinical trial. Medicine (Baltimore) 2017; Patients with heavily-pigmented Laser trabeculoplasty for open-angle 96: e6047. angles, like those with pigmentary glaucoma: a report by the American 20. Avery N, Ang GS, Nicholas S, et al. Academy of Ophthalmology. Repeatability of primary selective laser glaucoma, as well as patients with Ophthalmology 2011; 118: 2296–2302. trabeculoplasty in patients with primary previous compromise to the trabecular 4. Sethi HS, Naik M, Gupta VS. open-angle glaucoma. Int Ophthalmol meshwork, like those who have Management of glaucoma in pregnancy: 2013; 33: 501–506. risks or choices, a dilemma? Int J 21. Hodge WG, Damji KF, Rock W, et al. undergone previous ALT, or patients Ophthalmol 2016; 9: 1684-1690. Baseline IOP predicts selective laser with traumatic trabecular meshwork 5. Joseph A, Pasquale LR. Attributes trabeculoplasty success at 1 year post- associated with adherence to glaucoma treatment: results from a randomized damage are at a greater risk of IOP clinical trial. Br J Ophthalmol 2005; 89: 24 medical therapy and its effects on elevation following the procedure. glaucoma outcomes: an evidence-based 1157–1160. In these patients, prophylactic review and potential strategies to 22. Woo DM, Healey PR, Graham SL, et al. Intraocular pressure-lowering IOP-lowering medication, such as improve adherence. Semin Ophthalmol 2017; 32: 86–90. medications and long-term outcomes of apraclonidine or brimonidine, are 6. Ekici F, Waisbound M, Katz LJ. selective laser trabeculoplasty. Clin Exp typically instilled to dampen the IOP Current and future of laser therapy in Ophthalmol 2015; 43: 320–327. 23. De Keyser M, De Belder M, De Groot rise after treatment.24 the management of glaucoma. Open Ophthalmol J 2016; 10: 56–57. V. Randomized prospective study of 7. Katz LJ, Steinmann WC, Kabir A, et al. the use of anti-inflammatory drops Less common side-effects after SLT Selective laser trabeculoplasty versus after selective laser trabeculoplasty. J Glaucoma 2017; 26: e22–e29. include cystoid macular oedema and medical therapy as initial treatment of glaucoma: a prospective randomized 24. Harasymowycz PJ, Papamatheakis corneal haze.15 Those who may be trial. J Glaucoma 2012; 21: 460–468. DG, Latina M, et al. Selective laser at increased risk of cystoid macular 8. Okeke CO, Quigley HA, Jampel HD et al. trabeculoplasty (SLT) complicated by intraocular pressure elevation in eyes oedema are those patients with Interventions improve poor adherence with once daily glaucoma medications with heavily pigmented trabecular pre-existing pseudophakic macular in electronically monitored patients. meshworks. Am J Ophthalmol 2005; oedema, diabetic retinopathy or Ophthalmology 2009; 116: 2286–2293. 139: 1110–1113. history of retinal vein occlusion.15 9. De Keyser M, De Belder M, De Groot MARCH 2018 11

An overview of optical coherence tomography angiography (OCT-A)

the superficial retinal layers, the deep interface (VRI). Dr Rim Makhlouf retinal layers, the choriocapillaris and OD FAAO the choroid. Over the past few years, As microaneurysms and retinal numerous applications have emerged neovascularisation can sometimes using OCT-A, some of which are be indistinguishable on fluorescein Assistant Professor discussed in this article. angiography, OCT-A is an invaluable Nova Southeastern University method for differential diagnosis and College of Optometry, Florida, USA respective management.6 Capillary non- Diabetic retinopathy perfusion can be seen as areas of lack Diabetic retinopathy is a retinal of flow signal, commonly referred to microangiopathy characterised by as capillary drop-out. When it affects microaneurysms (the leakage of which the foveal area, it leads to an enlarged Optical coherence tomography leads to diabetic macular oedema), as and remodelled foveal avascular angiography (OCT-A) is an emerging well as capillary non-perfusion and zone (FAZ), a characteristic of foveal technology that provides a detailed ischaemia within the retina (which ischaemia that leads to decreased vascular map of the posterior pole leads to retinal neovascularisation). vision in its moderate-to-advanced through decorrelation techniques Using OCT-A, microaneurysms can stages. The presence of capillary drop- which detect changes between be visualised as demarcated saccular out and enlarged FAZ are predictors of consecutive b-scans taken at the or fusiform shapes of focally dilated diabetic retinopathy progression.7 same cross-section due to moving capillary vessels in the inner retina.2,3 erythrocytes (motion contrast).1 Choroidal neovascular membranes Even though the sensitivity of OCT-A (CNVMs) are characterised by the OCT-A is a non-invasive imaging tool in detecting microaneurysms may presence of abnormal blood vessels that has many potential applications in be lower than that of fluorescein that originate from the choroid and posterior segment disease as it provides angiography, OCT-A has the advantage may be seen in various conditions structural vascular information as well of allowing their three-dimensional such as wet age-related macular as functional blood flow information localisation within the inner retinal degeneration (AMD), high myopia for both the retinal and choroidal layers.4,5 Retinal neovascularisation on and central serous chorioretinopathy vasculatures without the use of dye. the other hand, appears as a hyper- (CSCR). OCT-A features associated with Different segmentations can be used to flow signal above the internal limiting CNVMs may include patterns described isolate different layers, some of which membrane and can be visualised using as small filamentous vessels forming include the vitreo-retinal interface, segmentation of the vitreo-retinal anastomoses (lacy wheel or sea fan), as well as vessels associated with a central trunk (Medusa).8,9

OCT-A vs FA In contrast to fluorescein angiography which remains the gold standard in detecting and classifying CNVMs, OCT-A allows a three-dimensional visualisation of the fibrovascular network, including their multi-planar location and morphology, which can be monitored to assess more accurate responsiveness to treatment. Its sensitivity may range between 50 per cent and 100 per cent depending on the underlying aetiology of the CNVM.8,10-13 For example, the presence of an overlying massive haemorrhage, which is more likely to occur in wet AMD, limits the visualisation of a Figure 1. Visualisation of a CNVM demonstrat- Figure 2. Visualisation of microaneurysms ing hyper-flow in a ‘sea fan’ pattern using a (arrows) as well as a remodelled and enlarged segmentation of the choroid FAZ in a patient with diabetic retinopathy Continued page 12 12 MARCH 2018

Limitations 5. Salz DA, de Carlo TE, Adhi M et al. Even though OCT-A is a powerful Select features of diabetic retinopathy OCT-A on swept-source optical coherence tool, it is not without limitations. tomographic angiography compared From page 11 The main limitation of OCT-A is the with fluorescein angiography and potential presence of artifacts. Motion normal eyes. JAMA Ophthalmol 2016; 134: 644–650. artifacts occur due to the principle 6. Hwang TS, Jia Y, Gao SS et al. Optical that the detection of movement in the coherence tomography angiography 9,12 features of diabetic retinopathy. Retina CNVM by blocking the signal. In back of the eye is translated as blood 2015; 35: 2371–2376. addition, OCT-A will detect a blood flow. Therefore, patient movements 7. Sim DA, Keane P, Zarranz-Ventura J et vessel only if its blood flow speed is or fixation losses result in the false al. The effects of macular ischemia on visual acuity in diabetic retinopathy. higher than a minimum threshold, appearance of areas of flow signal. Invest Ophthalmol Vis Sci 2013; 54: or slowest detectable flow, which is Conversely, blinking blocks light from 2353–2360. determined by the time between two reaching the back of the eye, which 8. Lupidi M, Coscas G, Cagini C, et 14 al. Optical coherence tomography sequential OCT b-scans. CNVMs translates into no movement and angiography of a choroidal may show areas of reduced blood flow, therefore into areas of absence of flow neovascularization in adult onset potentially making them completely or signal on the OCT angiogram, leading foveomacular vitelliform dystrophy: pearls and pitfalls. Invest Ophthalmol partially undetectable on OCT-A. to the false appearance of capillary Vis Sci 2015; 56: 7638–7645, drop-out. 9. Novais E, Baumal C. The clinical Polypoidal choroidal vasculopathy, utility of OCT angiography. Review of Ophthalmology 2017; 24: 51-55. an essential differential diagnosis Shadow artifacts, or ‘ghost images’ 10. Bonini Filho MA, de Carlo TE, Ferrara of AMD, is characterised by the occur due to moving shadows D et al . Association of choroidal presence of polypoidal lesions with created by moving erythrocytes in neovascularization and central serous chorioretinopathy with optical or without branching network on more superficial vessels, giving the coherence tomography angiography. indocyanine green angiography, false appearance of blood flow in JAMA Ophthalmol 2015; 133: 899–906. deeper layers. In addition, although 11. Jia Y, Bailey ST, Wilson DJ et al. which remains the gold standard in Quantitative optical coherence its diagnosis. However, OCT-A may be erythrocytes are hypothetically the tomography angiography of choroidal useful in identifying these structures only moving structures in the back neovascularization in age-related macular degeneration. Ophthalmology without the need of a dye. Using of the eye, white noise artifacts from 2014; 121: 1435–1444. segmentation of the choriocapillaris, moving non-vascular structures can 12. De Carlo TE, Bonini Filho MA, Chin AT the branching vascular network will occur, especially if the patient is et al. Spectral-domain optical coherence 14 tomography angiography of choroidal appear as a hyper-flow lesion whereas moving. Finally, obscuration from neovascularization. Ophthalmology the polypoidal lesion, which, in structures present in more superficial 2015; 122: 1228–1238. comparison, is likely to have unusual layers such as haemorrhages blocks 13. Moult E, Choi W, Waheed NK et al. Ultrahigh-speed swept-source OCT blood flow, will demonstrate lower light from getting to deeper layers, angiography in exudative AMD. flow, and will frequently appear as a which results in areas of absence of Ophthalmic Surg Lasers Imaging Retina hypo-flow round structure.15 flow signal on the OCT angiogram. 2014; 45: 496–505. 14. E de Carlo T, Romano A, Waheed NK, et al. A review of optical coherence OCT-A is a non-invasive tool that tomography angiography (OCT-A). Int J Glaucoma allows for the visualisation of retinal Retina Vitreous 2015; 1: 5. 15. Srour M, Querques G, Souied EH. Numerous studies have used OCT-A and choroidal vasculature, and is Optical coherence tomography to determine characteristics of optic invaluable in the diagnosis and angiography of idiopathic polypoidal neuropathies including glaucoma. It management of various chorioretinal choroidal vasculopathy. Dev Ophthalmol 2016; 56: 71–76. has been shown that there is decreased diseases. It has also enhanced our 16. Wang X, Jiang C, Ko T, et al. Correlation peripapillary capillary density in understanding of the pathophysiology between optic disc perfusion and of many posterior segment diseases glaucomatous severity in patients glaucomatous eyes and that this with open-angle glaucoma: an optical decrease correlates well with the including optic neuropathies, which coherence tomography angiography severity of glaucoma, as well as with opens doors to more indispensable study. Graefes Arch Clin Exp Ophthalmol 2015; 253: 1557–1564. ganglion cell complex thickness, retinal clinical applications in the future. 17. Lee EJ, Lee KM, Lee SH, Kim TW. OCT nerve fibre layer thickness and visual angiography of the peripapillary retina fields, in terms of both location and in primary open-angle glaucoma. Invest 16-18 Ophthalmol Vis Sci 2016; 57: 6265– extent. 6270. 1. Ferrara D, Waheed NK, Duker JS. 18. Bojikian KD, Chen CL, Wen JC, et al. Investigating the choriocapillaris and OCT-A is therefore a promising tool in Optic disc perfusion in primary open choroidal vasculature with new optical angle and normal tension glaucoma eyes detecting and monitoring progression coherence tomography technologies. using optical coherence tomography- in glaucoma. In eyes with optic atrophy Exp Eye Res 1973; 15: 15–29. based microangiography. PLoS One 2. de Barros Garcia JMB, Isaac DLC, Avila due to chronic optic neuropathies, 2016; 11: e0154691. M. Diabetic retinopathy and OCT 19. Ghasemi Falavarjani K, Tian JJ, Akil H, decreased peripapillary capillary angiography: clinical findings and future et al. Swept-source optical coherence density is seen corresponding to the perspectives. Int J Retina Vitreous 2017; tomography angiography of the optic 3: 14. disk in optic neuropathy. Retina 2016; region with retinal nerve fibre layer 3. Shibazawa A, Nagaoka T, Takahashi 19,20 36 Suppl 1: S168–S177. thinning. The characterisation A et al. Optical coherence tomography 20. Chen JJ, Abou Chehade JE, Iezzi R Jr, of various optic neuropathies using angiography in diabetic retinopathy: et al. Optical coherence angiographic a prospective pilot study. Am J OCT-A could provide a tool that would demonstration of retinal changes from Ophthalmol 2015; 160: 35–44. chronic optic neuropathies. Neuro- facilitate their differential diagnosis, 4. Couturier A, Mane V, Bonnin S et al. Ophthalmology 2017; 41: 76–83. allowing for their prompt and accurate Capillary plexus anomalies in diabetic retinopathy on optical coherence management. tomography angiography. Retina 2015; 35: 2384–2391. MARCH 2018 13

GUIDE Visual field chair-side reference guide PAGES 14-15 Visual Fields: past present and future

SAP uses an achromatic stimulus of Present – Using SAP in current Jack Phu fixed size (Goldmann size III) briefly clinical practice BOptom (Hons) BSc MPH FAAO presented for a constant duration (200 ms) upon an achromatically Visual field results analysis -2 Centre For Eye Health lit background (10 cd.m ). These SAP printouts differ between parameters have become the instruments, however, several clinical standard in both practice features are consistent to all, and large-scale clinical trials.11-14 and careful examination of these Common instruments that have been features is important for accurate developed for SAP testing include the interpretation (Figure 1). Reporting of Humphrey Field Analyzer (HFA), the Performing visual fields (VFs) is no Octopus perimeter and the Medmont easy task, not just for the patient, but Automated Perimeter. Continued page 18 also for clinicians and technicians. Although it is an essential component of the ophthalmic examination, there has been a recent paradigm shift towards increased reliance upon automated technologies such as optical coherence tomography (OCT).1 In contrast to the quick, painless, repeatable and objective measurements obtained using the OCT,2 VF testing is a long, tiring and variable process that relies on the subjective responses of an inexperienced observer.2 Learning effects are known to be present with VF testing, and defects need to be repeatable for a conclusive diagnosis.3,4

The question then is: why do we continue to assess VFs in clinical practice, given its numerous disadvantages?

Past – Standard automated perimetry (SAP) as the clinical standard of VF assessment Previous papers have presented an overview of the development of perimetry.5 Methods for measuring the VF have evolved from qualitative techniques such as the tangent screen,6 to instruments that could quantify VF sensitivity.7,8 The age of supercomputers boosted the potential for quicker quantitative measurements, 1. Reliability indices 5. Visual Field Index (VFI) and many fast adaptive algorithms have 2. Gaze tracker result 6. Mean deviation (MD) and pattern standard Sensitivity results (in dB) deviation (PSD) since usurped the traditional staircase 3. 4. Glaucoma Hemifield Test (GHT) 7. Pattern deviation map method for determining sensitivity across the VF.9 SAP has subsequently Figure 1. Analysis of a typical Humphrey Field Analyzer printout. These or similar indices may become the clinical standard for also be available on different instruments. To understand the different maps and indices re- quantitative VF assessment since its ported by the instrument, a careful reading of the manufacturer’s manual is strongly recom- introduction in the 1970s.7,8,10 mended. There may be variability in the meaning of the automated analyses. Chair-side Reference: Visual Field ChairChair--sidesideChairChair Reference:Reference:--sideside Reference:Reference: VisualVisual FieldField VisualVisual FieldField Visual field examination, in particular, standard automated perimetry, remains the most commonly utilised functional assessment. Many ocular and neurological diseases and conditions are known to exhibit distinct visual field loss Visual field examination, in particular, standardChair automated perimetry-side, remains Reference: the most commonly utilised functional Visual assessment. 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Differentials:• Optic neuritis Vertically oriented field defects should alwaysVertically raise oriented•Unilateral Unilateralthe Presuspicion -fieldchiasmal: : defects of pathologiesor should anterior always onchiasmal theraise the lesion suspicion (e.g. ofcompressive pathologies lesionson the ) Description: Field loss extendingDescription: from blindspot Field loss to• extending Optic• Opticneuritis from neuritis blindspot to • NAION/AIONDescription: Field loss Description:respecting• Papilloedema theField nasal loss respectinghorizontalDifferentials: •the nasalPapilloedema horizontal • High myopia Differentials:interpreted critically• Retinal (reliability disease and repeatability)• Retinal anddisease in conjunction with other clinical signs, symptoms papillomacular bundle. Differentials:Differentials: Differentials: •• GlaucomaGlaucoma ••• GlaucomaOpticOptic neuritisneuritis • Optic neuritis VisualResults field must examination, be interpreted in particular, critically (reliabilitystandard automatedand repeatability) perimetry and, inremains conjunction•• PreRetinal the-chiasmal mostdisease withvisual orcommonly other anterior pathway •clinical• chiasmalbeyond RetinalRetinalutilised signs, thedisease diseaselesion functional retina,symptoms (e.g. particularly compressive assessment.and examinationif it respects lesions Many the) findings. vertical ocular midline. and neurological diseases and conditions• fixation.areOptic known neuritisMust includeto exhibit •fixationDifferentials: Differentials:Cilioretinal• distinct andNAION/AION doesartery visual not occlusion obey field loss midline• Optic• with Papilloedemanerve at least drusen 1 abnormal point•••• OpticGlaucomaoutsideGlaucomaHigh nerve myopia 15⁰ . Nodrusen ••• RetinalOpticOptic neuritis neuritis disease visualUnilateral pathway beyond the• retina,Pre- chiasmalparticularly or ifanterior it respects• chiasmal Pre the-chiasmal vertical lesion or (e.g.midline. anterior compressive chiasmal lesions lesion) (e.g. compressive lesions) fixation. Must include fixation• andOptic does neuritis not obey • •• CilioretinalOpticNAION/AION neuritis artery • • MacularNAION/AIONDifferentials:midline disease with at least 1 abnormal• Papilloedema point outside 15⁰. No•• PapilloedemaHigh myopia • High myopia and: examination• findings. Pre-chiasmal or anterior• chiasmalPre-chiasmal lesion or (e.g. anterior compressive chiasmal lesions lesion) (e.g. compressive lesions) •• horizontalCilioretinalOptic neuritis midline. artery Usually • NAION/AION••• dueOptic MaculartoNAION/AION damage neuritis disease of the • NAION/AION more• Optic ••than OpticPapilloedemaneuritis1 point nerve may bedrusen on the •temporal••• PapilloedemaPapilloedemaRetinalHigh side. myopia disease •• HighHigh myopia myopia patterns, and thus, visual field testing may therefore assist with a differential diagnosis. The abilityBilateral• toPre map- chiasmal(homonymous): the depth,or anterior extent chiasmal and changelesion (e.g. of compressivevisual field lesionsdefects) shouldhorizontal be midline.considered Usually in clinicaldue to damage management of the decisions.•• occlusionOpticCilioretinal neuritisThe more artery common ••• RetinalNAION/AIONMacular more disease disease than 1 point may be on• theOptic temporal nerve side.drusen •• OpticRetinal nerve disease drusen • Retinal disease • Retinal disease Differentials: Differentials: •• papillomacularocclusionCilioretinalCilioretinal artery arterybundle. • Macular•• RetinalMacular Maculardisease disease diseasedisease • Glaucoma • High• Optic myopiaOptic neuritis nerve drusen • Retinal disease types of visual field defects and their differentials areDifferentials: outlined below. Bilateral (homonymous): • Post -chiasmal lesion (e.g. compressive lesions, stroke, injuries) papillomacular bundle. ••• CilioretinalCilioretinal artery artery •• MacularMacular disease disease •• OpticOptic nerve nerve drusen drusen •• RetinalRetinal disease disease Vertical Field Loss Pattern • Pre-chiasmal or anteriorBilateralBilateral chiasmal (homonymous):(homonymous):Centrocecal lesionUnilateral (e.g. : Bilateralcompressive (homonymous): lesions) Nasal• Optic Step neuritis • NAION/AIONocclusionocclusion • Retinal•• occlusionRetinalRetinaldisease diseasedisease • Retinal• Papilloedemadisease Differentials:• RetinalHigh diseasemyopia Unilateral: • Post-chiasmal lesion Bilateral(e.g.Bilateral compressive (homonymous): (homonymous): lesions, stroke, injuries) occlusionocclusion •• RetinalRetinalDifferentials: disease disease Results must be interpreted critically (reliability and repeatability) and in •conjunctionPost-chiasmal with• lesion Retinalother (e.g. •diseaseclinical compressivePost -signs,chiasmal symptoms lesions, lesion stroke,(e.g. and compressive injuries)examination lesions, findings. stroke, injuries) • Cilioretinal artery • Differentials:Macular disease • Optic nerve drusen •• GlaucomaRetinal disease • Optic neuritis • Post-chiasmal lesion •(e.g.• Post compressivePost-chiasmal-chiasmal lesions,lesion lesion (e.g. (e.g.stroke, compressive compressive injuries) lesions,lesions, stroke, stroke, injuries) injuries) Altitudinal Glaucoma Arcuate Optic neuritis Vertically oriented field defects should always raise the suspicion• BilateralRetinal of pathologies (homonymous):disease on the • Pre-chiasmalBilateral or ( banterioritemporalDescription: chiasmal/binasal lesion Field): (e.g.loss extendingcompressive from lesions blindspot) to Differentials:occlusion •Description:Retinal• Optic disease Field neuritis loss respecting• theNAION/AION nasal horizontal • • Papilloedema• • High myopia Vertical FieldBilateral Loss (bitemporal Pattern/binasal): Altitudinal Altitudinal ArcuateArcuate visual pathway beyond the retina, particularly if it respects• the• Pre verticalPost-chiasmal-chiasmal midline. or anterior lesion Bilateral (e.g. chiasmal compressive (bitemporal lesion (e.g.lesions, /binasal compressive• Bilateral stroke,):Chiasmal injuries)(b itemporallesions lesionsfixation. ) (pituitary/ Mustbinasal include): adenoma, fixation meningioma, and does not parasellar obey carotidAltitudinal artery• Optic neuritis Altitudinalmidline• • NAION/AION withCilioretinal at least artery 1 abnormal • pointMacular outside disease 15⁰ . No Arcuate• Papilloedema Arcuate• Optic• Highnerve myopia drusen • Retinal disease •BilateralChiasmal (bitemporal lesions /(pituitarybinasalBilateralBilateral): adenoma, ( b(bitemporalitemporal meningioma,//binasalbinasal): ) :parasellar carotid artery Altitudinal AltitudinalAltitudinal Arcuate ArcuateArcuate Vertical Field Loss Pattern Vertically-oriented• fieldChiasmal defectsCentrocecal lesionsBilateral should (pituitary (homonymous): always• aneurysm, Chiasmaladenoma, raise the horizontal lesionsmeningioma, meningioma,suspicion (pituitary midline. of craniopharyngioma pathologiesparasellar adenoma,Usually duecarotid on meningioma, tothe damage ,arteryvisual glioma) ofpathway parasellar the beyond carotid •arteryNasalCilioretinal Step artery more• Macularthanocclusion 1 point disease may Description:be on •the temporalRetinal Field disease loss side. that respects the •horizontalOptic nerve drusen • Retinal disease Description: Field loss extending from the blind spot to • aneurysm,Chiasmal lesions meningioma, (pituitary• craniopharyngiomaChiasmalChiasmal adenoma, lesions lesions meningioma, (pituitary (pituitary, glioma) parasellar adenoma, adenoma, carotid meningioma, meningioma, artery parasellar parasellar carotid carotid artery artery Description: Field loss thatDescription: respects Field the loss horizontal Description:Description: Field loss Field extending loss fromextending from the blind spot to Differentials: BilateralBilateral (homonymous):the (b retina,itemporal particularly/binasal aneurysm,): if it respects meningioma,• Post the-chiasmal ••vertical craniopharyngiomaTiltedaneurysm, lesion midline.disc (e.g.papillomacular meningioma, compressive, glioma) bundle. lesions,craniopharyngioma stroke, Altitudinalinjuries), glioma) occlusion Description: • Retinal Field disease loss thatmidline.Description: respectsArcuate the Field horizontal loss that respects the horizontal Description: Field loss extendingtheDescription: nasal from field the Fieldwith blind lossat leastspot extending oneto point from outside the blind 15⁰ spot to • Tiltedaneurysm, disc meningioma, craniopharyngiomaaneurysm, meningioma,, glioma) craniopharyngioma , glioma) midline.Description: Field loss thatthatDescription: respects the the horizontalField horizontal loss that respects the horizontal the blindtheDescription: spotnasal to thefield nasal Field with field loss at leastwithextending atDescription: one point from outside theField blind loss 15 spot⁰extending to from the blind spot to VerticallyUnilateral oriented: field defects should always raise the suspicion• Post of-chiasmal pathologies lesion on (e.g.the compressive lesions, stroke,aneurysm, injuries) meningioma,Description: Fieldcraniopharyngioma loss extending ,from glioma) blindspot to Differentials:Description: Field loss Description:midline. respecting Field the lossnasal that horizontal respects the horizontal nasallyDescription:the nasal and field at Field least with loss one at extending leastabnormal one pointfrom point theoutside temporally. blind 15 spot⁰ to • Chiasmal lesions (pituitary•• TiltedTilted adenoma, discdisc meningioma,Vertical• Tiltedparasellar field disc loss carotidcan be arteryclassified into the following midline.midline. midline. least nasallytheonethe pointnasalnasal and outside fieldfield at leastwith15⁰with nasally oneatat leastleast andabnormal oneone pointpoint point outsideoutside temporally. 1515⁰⁰ visual pathway beyond the retina, particularly if it respects the vertical midline. Vertical field lossBilateral can be ( classifiedb•itemporal• TiltedTilted into/binasal disc disc theDifferentials: fixation. ) :following Must include fixation and does not obey Altitudinal • midlineGlaucoma with at leastDifferentials:midline.midline. 1 abnormal• Optic pointneuritis outside 15⁰. NoArcuate thethe nasal nasal field field with with at at least least one one point point outside outside 15 15⁰⁰ • Retinal disease aneurysm, meningioma, craniopharyngioma,patterns: glioma) Description: Field loss that respects the horizontal Differentials: Description: Field loss extendingat leastnasally one from abnormal and the atblind pointleast spot temporally. one to abnormal nasally andpoint at temporally. least one abnormal point temporally. VerticalVertical fieldfield lossloss• cancanChiasmal bebe classifiedclassifiedVertical lesions intointofield (pituitary the theloss followingfollowing can adenoma, be classified meningioma, into the parasellar following carotid artery Differentials: nasally and at least one abnormalnasallynasally and and point at at least temporally.least one one abnormal abnormal point point temporally. temporally. • Pre-chiasmal or anterior chiasmal lesion (e.g. compressiveBilateral• lesionsTilted Differentials(bitemporal) disc /binasalpatterns:): 1.VerticalVertical Vertical field field Step: loss loss• horizontal can canOptic be be classified classified neuritismidline. into intoUsually the the• followingdue followingAltitudinalNAION/AION to damage of the midline. Differentials:• morePapilloedema than 1 point • may Differentials:Branch• •beBranch retinalonHighArcuate the retinalmyopia artery/ temporal side.• Advancedthe nasal glaucoma field with at leastDifferentials: one point outside 15⁰ Differentials: patterns:patterns: aneurysm,patterns: meningioma, craniopharyngioma, glioma) Differentials:• Description:Branch retinal Field loss Differentials: Differentials:that• respectsAdvanced the horizontal glaucoma Description:Differentials: Field loss extending from the blind spot to Differentials: • Chiasmal lesions (pituitary1. Vertical adenoma, Step: meningioma,patterns:patterns: parasellar carotid•papillomacularCilioretinal artery bundle.artery • Macular disease • • Branch Optic retinalnerve drusen vein •• • occlusionartery/veinBranchAdvancedRetinal retinal disease occlusionglaucoma • • CorticalAdvancednasally disease and glaucoma at least(if one abnormal• GlaucomaDifferentials: point temporally. Differentials:• Glaucoma • High myopia Vertical field loss can be1. classified Vertical Step:into the• followingTiltedGenerally disc1. Vertical respects Step: the vertical midline with at least 2 points • midline.artery/veinBranch retinal occlusion ••• BranchCorticalAdvanced retinal disease glaucoma (if • Advanced glaucoma the nasalDifferentials:• fieldGlaucoma with at least one pointDifferentials:• outsideHigh myopia15 ⁰ UnilateralBilateral: (homonymous): aneurysm,Unilateral: meningioma,Generally1. Vertical craniopharyngioma respects Step: theBilateral vertical, glioma)1.1. Vertical Vertical midline(homonymous): Step: Step: with atocclusion least 2 points Bilateral (bitemporal/binasal):• Retinal disease Differentials:Description: Field loss that respectsDifferentials: the horizontal • NAION/AION•• NAION/AIONBranch retinal • bilateral,Advanced Description: rare) glaucoma Field loss• extending Papilloedema from the blind spotDifferentials: •to PapilloedemaGlaucoma • BranchHigh myopia retinal patterns: Generally respects the verticaloutsideGenerally midline 15⁰ respects of with fixation. at the least vertical 2 points midline with at least 2 points artery/veinartery/vein occlusionocclusion •• artery/veinCorticalCortical diseasedisease occlusion (if(if • Cortical disease (if nasally•• andPapilloedemaGlaucomaGlaucoma at least one abnormal point••• temporally.BranchHighHigh myopiamyopia retinal • • Post-chiasmal lesion (e.g. compressive lesions, stroke, injuries) outsideGenerally 15⁰ respects of fixation.Vertical the verticalfield loss midline can be classified withDifferentials: at leastinto the 2 points following midline.• Branch retinal •• AdvancedNAION/AION• Glaucoma glaucoma • Retinal• Retinalartery/veinartery/vein bilateral,disease• diseaseOptic rare) occlusion occlusion neuritis •• CorticalCorticalDifferentials:the disease diseasenasal field (if (if with at• least Optic •one nerve point drusen outside 15⁰ •••• OpticGlaucomaGlaucoma nerve drusen •• artery/veinHighHigh myopia myopia occlusion • Retinal disease • 1.Tilted Vertical• Retinaldisc Step: disease • Post-chiasmal GenerallyGenerally respectslesion respects the the vertical vertical midline midline• Chiasmal with with lesions at at least least (pituitary 2 2 points points adenoma, meningioma, • Differentials:NAION/AION • NAION/AIONbilateral, rare) bilateral, rare) • Papilloedema •• PapilloedemaBranch retinal • Branch retinal outsideoutside 15⁰15⁰ ofof fixation.fixation.patterns: outside 15⁰ of fixation. •• RetinalNAION/AION disease • Advanced•• NAION/AIONNAION/AION bilateral, glaucoma rare) bilateral,bilateral, rare) rare) • Optic•• neuritisOpticPapilloedema nerve drusen ••• PapilloedemaPapilloedemaartery/veinBranch retinal occlusion • • BranchBranch retinal retinal • Pre -chiasmal or anterior chiasmal lesion (e.g. compressive lesions• Pre-chiasmal) or anterior chiasmal (compressiveoutsideoutside 15⁰ 15⁰ lesions, of of fixation. fixation. • Optic neuritisparasellar carotid• NAION/AIONartery aneurysm, meningioma, artery/vein occlusion •• CorticalRetinal• Papilloedema disease (if • Retinal • High disease myopia • nasallyGlaucoma and at least one abnormal• • HighOptic myopiapoint nerve temporally. drusen • • OpticOpticartery/vein neuritis nerve occlusion drusen • Retinalartery/vein disease occlusion VerticalGenerally field respectsloss can thebe classified vertical midline into the with1. following Vertical at least Step: 2 points • •RetinalBranch disease retinal • Cortical• • Retinal diseaseAdvanced disease(if bilateral, glaucoma rare) •Differentials: High• •myopiaOpticOptic neuritisnerve drusen •• OpticRetinalartery/vein nerve disease drusenocclusion artery/vein occlusion Bilateral (bitemporal/binasal): lesion (compressive lesions) Altitudinalstroke, injuries) • Cilioretinal craniopharyngioma,artery • Macular glioma) disease ArcuateDifferentials:• NAION/AION bilateral,• Optic rare) nerve drusen• Retinal • diseaseRetinal disease • Papilloedema • Branch retinal • Optic nerve drusen artery/vein occlusion patterns:outside 15⁰ of fixation. Generally respects the vertical midline with at least 2 points artery/vein occlusion • Cortical disease (if • Branch• ••Glaucoma retinalOpticOptic artery/vein neuritisneuritis occlusion • High••• myopiaOpticRetinalRetinal neuritis diseasedisease • Retinal disease Bilateral• Chiasmal (homonymous): lesions (pituitary adenoma, meningioma, parasellar carotid artery occlusion • Tilted disc • Retinal disease •• RetinalBranch disease retinal • Advanced glaucoma • Differentials:Optic nerve drusen artery/vein occlusion •• OpticOptic neuritis neuritis •• RetinalRetinal disease disease 1. Vertical Step: outside 15⁰ of fixation. • NAION/AION bilateral, rare) • Retinal• Papilloedema disease • Branch retinal aneurysm, meningioma, craniopharyngioma, glioma) Description: Field loss that respects the horizontal TemporalDescription: Wedge Field loss extending from the blind spot to • Optic neuritis Paracentral• Retinal disease • Post-chiasmal lesion (e.g. compressive lesions, stroke,Generally injuries) respects the vertical midline with at least2. 2 Quadrant:points artery/vein occlusion • • CorticalRetinal disease disease (if • Glaucoma • Optic• Highnerve myopia drusen artery/vein occlusion • Tilted disc midline. Temporal Wedge the nasal field with at least one point outside 15⁰ Paracentral Vertical field loss2. Quadrant: can be classified into the four following patterns: Temporal• NAION/AION Wedge Temporalbilateral, Wedge rare) Paracentral• Papilloedema Paracentral• Optic• Branchneuritis retinal • Retinal disease outside 15⁰ of fixation. 2. Quadrant: Visual2. Quadrant: field loss that respects both the vertical & Temporal Wedge TemporalTemporalnasally Wedge and Wedge at least one abnormal point temporally. ParacentralParacentral Paracentral BilateralVertical ( bfielditemporal loss can/binasal be classified): into the following Visual2. Quadrant: field lossAltitudinal that respects2. 2. Quadrant: Quadrant: both the vertical & •ArcuateRetinal disease Temporal Wedge Description: Small visual field defect temporal• Optic to nerveblind drusenParacentral artery/vein occlusionDescription: A small visual field abnormality not Visual field loss that respectshorizontalVisual both field themidline. loss Differentials:vertical that Suggestive respects& of both neurological the vertical involvement & Description: Small visual field defect temporal to blind Description: A small visual field abnormality not • patterns:Chiasmal lesions (pituitary adenoma, meningioma, parasellar carotid artery horizontalVisual field midline. loss that Suggestive respectsVisual ofboth neurologicalfield the loss vertical that involvement respects & both the verticalTemporal & Wedge spot. Paracentral • Optic neuritis • Retinal disease contiguous to the blind spot and within 15⁰ of fixation. 2. Quadrant:1. Vertical Step ifVisual bilateral. field All loss points that2. Quadrant withinrespects the both quadrant the vertical must be& P<5%. Description:Description: SmallSmall visualvisualDescription: fieldfieldDescription: defectdefect Small temporaltemporal visual Small field visual toto blindblind field defect temporal to blind Description:Description:Description: A small visualAA smallsmall field visualvisual Description: fieldfield abnormalityabnormality A small notnot visual field abnormality not horizontalhorizontal midline.midline. SuggestiveSuggestivehorizontal ofof neurologicalneurological midline.Description:• BranchSuggestiveinvolvementinvolvement retinal Field of neurologicalloss that• respectsAdvanced involvement the glaucomahorizontal Temporal Wedge spot.Differentials:Description: Field loss Description:Description: extending from Small Small the visual visual blind field field spot defect defect Paracentralto temporal temporal to to blind blind contiguous to the blind spot Description:Description: and within A A 15small small⁰ of visual fixation.visual field field abnormality abnormality not not 1. Verticalaneurysm, Step: meningioma, craniopharyngioma, glioma) Visual field loss that respectsif bilateral. both All the points 2.vertical Quadrant: within &Note:horizontal horizontal the Pituitaryquadrant midline. midline. gland must Suggestive Suggestive adenoma be P<5%. of givesof neurological neurological more superior involvement involvement defects spot. defectspot. temporal to blind spot. abnormalitycontiguous not contiguous to the blind to the spot contiguous and within to 15 the⁰ of blind fixation. spot and within 15⁰ of fixation. if bilateral. All points withinif thebilateral. quadrant All points mustartery/vein bewithin P<5%. the occlusion quadrant • mustCortical be P<5%. disease (if Description: Small visual field spot.• defect Glaucoma temporal to blindspot.spot. • High myopia Description: A small visual field contiguous abnormality to notthe blind spotcontiguouscontiguous and within to to the 15the⁰ blind ofblind fixation. spot spot and and within within 15 15⁰⁰ of of fixation. fixation. • GenerallyTilted disc respects the vertical midline with at least 2 points horizontal midline. SuggestiveNote:if bilateral. Pituitary of Generallyneurological All pointsglandVisual respects adenoma within involvementfield iftheif lossbilateral. bilateral. thevertical thatgives quadrant respects Allmore All points pointsmidline. must superior both within withinbe the P<5%. defectsvertical the the quadrant quadrant & must mustVisual be be field P<5%. P<5%. loss that respects both the nasal field with atDifferentials: least one point outside 15⁰ blind spot and within 15⁰ of fixation.Differentials: Note: Pituitary gland adenoma(“pieNote:- ingives -Pituitarythe -moresky”) •gland superiorwhileNAION/AION adenoma parasellar defects gives lesions more give superior morebilateral, inferior defects rare) spot. Differentials: • Description:Papilloedema Small visualDifferentials: field• defectBranch temporal retinal to blind contiguous to the blind spotDescription: andDifferentials: within A 15small⁰ of visual fixation. field abnormality not outside 15⁰ of fixation. if bilateral. All points within(“pieNote: the-in Pituitary- thequadrantmidline-sky”) gland horizontalwith whilemust at adenoma least beparasellar midline. Note:P<5%. 2 points gives Pituitary Suggestive lesions more glandgive superiorof neurologicalmore adenoma defectsinferior givesinvolvement more superiorTemporalthe vertical defects and Wedge horizontal midline. nasally and at least one• abnormalOpticParacentral neuritis point temporally. • Retinal disease • Glaucoma • Optic neuritis Vertical field loss can be classified into the following 2. Quadrant: lossesNote: Pituitary(“pie-on- thegland-ground”). adenoma gives more superior defects Differentials:Differentials:spot. • OpticDifferentials: neuritis Differentials:contiguousDifferentials:Differentials: to the blind spot and withinDifferentials: 15⁰ of fixation. (“pie(“pie--inin--thetheoutside--sky”)sky”) if15⁰ bilateral.whilewhile of fixation. parasellarparasellar All(“pie points-in -lesionslesions thewithin-sky”) Differentials: •thegivegive while quadrant Retinal moremore parasellar inferiorinferior disease must be lesions P<5%. giveSuggestive more inferiorof neurological involvement • • Optic Optic neuritis nerve drusen Differentials:Differentials:• Retinalartery/vein disease occlusion • Glaucoma Differentials:Differentials:• Optic neuritis patterns: VisualNote: field Pituitary loss that gland respects adenomalosses both (“pie gives the-on more vertical-the -superiorground”). & (“pie(“pie defects -in-in-the-the -sky”)-sky”) while while parasellar parasellar lesions lesions give give more more inferior inferior • Optic neuritis • Glaucoma• •• GlaucomaOpticRetinal (rare) neuritis disease (rare) • Retinal disease • Glaucoma• Glaucoma • •• PapilloedemaGlaucomaOptic neuritis • • HighOptic myopia neuritis losseslosses (“pie(“pie--onon--thetheNote:--ground”).ground”). Pituitarylosses gland (“pie adenoma-on-the gives-ground”). more superior defectsif bilateral. All points within the Differentials: •• • GlaucomaOpticOptic neuritis neuritis (rare) • Retinal•••• OpticOptic RetinaldiseaseRetinal neuritis neuritis diseasedisease •• RetinalRetinalDifferentials: disease disease • Papilloedema•• PapilloedemaGlaucoma •••• GlaucomaGlaucomaHighOptic myopia neuritis •• OpticOptic neuritis neuritis 1. Vertical Step: (“pie-in-the-sky”) while parasellar lesions give morelosseslosses inferior (“pie (“pie -on-on-the-the•-ground”).-ground”).Branch retinal • Advanced glaucoma Description: Small visual field• defectDifferentials:GlaucomaDifferentials: temporal (rare) to blind• Glaucoma (rare) Description: A small visualDifferentials:• fieldPapilloedema abnormality not • •• OpticPapilloedemaHigh nerve myopia drusen • High myopia horizontal midline. Suggestive of neurological(“pie -involvementin-the - sky”) while parasellar lesions give more inferiorquadrant must be p < 5%. • Optic neuritis •• RetinalGlaucoma disease (rare) • Glaucoma (rare) • Glaucoma • •Optic•• Optic nerveOpticPapilloedema neuritis drusen nerve drusen •• PapilloedemaHigh myopia • High myopia losses (“pie-on-the-ground”). artery/vein occlusion • Cortical disease (if spot. • • OpticGlaucoma neuritis • • GlaucomaRetinal• High disease(rare) myopia contiguous to the blind• spotGlaucoma and within 15⁰ of •fixation.Optic•• PapilloedemaneuritisOptic nerve drusen • High myopia Generally respects the vertical midline with at least 2 pointsif bilateral. All points within the quadrant lossesmust be(“pie P<5%.3.- on Hemianopia-the -ground”).: Note: Pituitary gland adenoma gives • Glaucoma (rare) • Papilloedema • •Optic•• High neuritisOpticOptic myopia nervenerve drusendrusen 3. Hemianopia: • NAION/AION bilateral, rare) • GlaucomaPapilloedema (rare) • Branch retinal Papilloedema High•• myopiaOpticOptic nerve nerve drusen drusen outside 15⁰ of fixation. Note: Pituitary gland adenoma gives Temporalmore superior WedgeLoss defects of the vertical hemifield respecting the morevertical superior midline defects (‘pie-in-the-Paracentral • •• High myopia • 2. Quadrant: 3.3. HemianopiaHemianopia:: 3. Hemianopia: Optic nerve drusen artery/vein occlusion • Differentials:Optic nerve drusen (“pie-in-the-sky”) while parasellarLoss of the lesions vertical give hemifield moreeither3. 3.inferior Hemianopia Hemianopia respecting partially :theor : •completely. verticalRetinal midline disease sky’) while parasellar lesions give moreDifferentials: • • Optic nerve drusen Visual field loss that respects both the vertical & 3. Hemianopia: LossLoss ofof thethe verticalvertical hemifieldhemifieldLoss respectingrespecting of the vertical thethe verticalvertical hemifield midlinemidline respecting the vertical midline Optic neuritis Retinal disease losses (“pie-on-the-ground”).either partially or3. completely.HemianopiaNote:LossLoss: of of Monocular the the vertical verticalDescription: temporal hemifield hemifield hemianopiaSmall respecting respecting visual fieldmaythe the inferiorvertical defectoccurvertical losses if temporalmidline themidline (‘pie-on-the-ground’). to blind • Optic neuritis •Description:Retinal• disease A small visual field abnormality• not • Glaucoma • Optic neuritis horizontal midline. Suggestive of neurological involvement Loss of the vertical hemifieldeithereither respecting partiallypartially oror the completely.completely. verticaleither midline partially or completely. Enlarged Blind Spot Clover Leaf Note: MonocularLoss temporal of thelesioneither verticaleither hemianopia ispartially partially hemifieldmore anterior mayor spot.or respecting completely. completely. occur and if theonly the vertical affecting midline the nasal crossing • Glaucoma (rare) contiguous to the blind spot and within 15⁰ of fixation. • Papilloedema • High myopia if bilateral. All points within the quadrant must be P<5%. either partially or completely.Note:Note: Monocular Monocular temporaltemporalNote: hemianopiahemianopia Monocular maymay temporal occuroccur ifif thethe hemianopia may occur if the Enlarged Blind Spot Clover Leaf lesion is more anterioreither partially andfibresNote:Note: only or from Monocularcompletely.affecting Monocular the ipsilateral the temporal temporal nasal eye.crossing hemianopia hemianopia may may occur occur if if the the Enlarged Blind Spot Enlarged Blind Spot Clover• LeafOptic nerve drusenClover Leaf Note: Pituitary gland adenoma gives more superior defects Note: Monocular temporallesionlesion hemianopia isis moremore anterioranterior may occur andandlesion ifonlyonly the affecting affectingis more anterior thethe nasalnasal and crossingcrossing only affecting the nasal crossing Enlarged Blind SpotEnlargedEnlarged Enlarged Blind Blind Blind Spot Spot Spot CloverClover Leaf Leaf CloverClover Leaf Leaf Description: Diagonal paracentral points show normal 2. Quadrant: fibres from theTemporal ipsilateralNote: Monocular lesionWedgeeye.lesion is temporalis more more anterior anterior Differentials:hemianopia and and mayonly only occur affecting affecting if the the the nasal nasal crossing crossing Paracentral Differentials: Description: Visual field loss involving at least two Description: Diagonal paracentral points show normal (“pie-in-the-sky”) while parasellar lesions give more inferior3. Hemianopialesion is more: anterior fibresand only from affecting the ipsilateral the nasal eye.fibres crossing from the ipsilateral eye. Enlarged Blind Spot Enlarged Blind Spot Description: Visual field loss involvingClover at Leaf least two Clover Leaf or near-normal sensitivity but all other points 3. Hemianopia fibres from the ipsilaterallesion is more fibreseye. anterior from and the only ipsilateral4. affectingThree Quadrantseye. the nasal crossing pointsDescription: contiguous Visual to fieldthe blind loss involvingspot. at least two Description:Description: Diagonal paracentral Diagonal points paracentral Description: points Diagonal show normal paracentral points show normal Visual field loss that respects both the vertical & Loss of the vertical hemifield respecting the vertical fibres midline from the ipsilateral• Optic eye.neuritis • Retinal disease pointsDescription:Description:• Glaucomacontiguous VisualVisual to fieldfield theDescription: loss lossblind• involvinginvolving spot.Optic Visual atneuritisat field leastleast loss twotwo orDescription: near-normal Diagonal sensitivity paracentralDescription: Description:but all other points Diagonal Diagonalpoints show normalparacentral paracentral points points show show normal normal losses (“pie-on-the-ground”). fibres from the ipsilateral eye. fibres from the ipsilateral eye.Description: Small visual field defect temporal to blind Description: A small Description:Description: visual field Visualabnormality Visual field field loss lossnot involving involving at at least least two two show normalor ornear near-normal-normal sensitivity sensitivity butreduced. butor near all other- normalThis ispoints often sensitivity due to but patient all other responding points horizontal midline. Suggestive of neurological involvementeither partially or completely. 4. Three Quadrants:• Glaucoma (rare) Description: Visual field losspoints involving• Description: Papilloedemacontiguous at least Visual totwo the field involving blind pointsloss• spot.involvingat Highleastcontiguous twomyopia at points least to two the blind spot.Description: Diagonal paracentralDescription:reduced.or near points- Diagonalnormal This show is oftensensitivitynormalparacentral due ortobut points patientnear all other-shownormal responding normalpoints sensitivity but all other points points contiguous to the blindpointspoints spot. contiguous contiguous to to the the blind blind spot. spot. all other points reduced. This is often due normallyor near-normal at the startsensitivity of the but test all only other as pointsthe visual field 4. Three Quadrants:Loss of the vertical hemifield spot. Three quadrants with all points at least points contiguous to the blind • spot.pointscontiguousOptic contiguous nerve todrusen thetocontiguous the blind Differentials: blind spot spot. to andthe blindwithin spot. 15 ⁰ of fixation.or near-normal sensitivity orbut near reduced.reduced.all -othernormal pointsThisThis sensitivity isis oftenoften but duedue all toreduced.toother patientpatient points This respondingresponding is often due to patient responding if bilateral. All points within the quadrant must be P<5%. Note: Monocular temporal4. Threehemianopia Quadrants: may occur Three if4. the Three quadrants Quadrants: with all points at least P<5%. Partial three Differentials: to patient normallyresponding atnormally the start at the ofstart the instrumentreduced.reduced. test only This This generallyas is theis often often visual test due due field these to to patient patient points responding responding first. Often Three4. Three quadrants Quadrants:respecting with the allvertical points4. Three midline at least Quadrants: P<5%. Partial three p Enlarged< 5%. Blind Spot Differentials:• PapillioedemaClover Leaf • Opticreduced. nerve This is often due reduced.to patientnormally This responding isat often the start due to of patient thenormally test responding only at as the the start visual of fieldthe test only as the visual field Note:3. Hemianopia Pituitary gland: adenoma gives more superior defectslesion is more anterior and only affecting 4.the Three nasal Quadrants: quadrant4.crossing Three Quadrants: losses does not have all points P<5% but is Differentials:Differentials: Differentials: of the test onlyinstrumentnormally as the visual at generally the field start instrument testof the these normally test pointsonly at as thefirst. the start Oftenvisual of fieldthe test only as the visual field 4. Three Quadrants: ThreeThree quadrantsquadrantseither partially withwith allall or pointspointscompletely.Three atat quadrants leastleast P<5%.P<5%. Differentials:with PartialPartial all points threethree at least P<5%. Partial three • PapillioedemaDifferentials: • PapillioedemaDifferentials:Differentials:• Optic nerve normally at the start of the test accompaniednormallyonlyinstrument as the at visual thegenerally by start fieldhigh offixation test the these test loss only points and as false thefirst. negative.visual Often field (“pie-in-the-sky”) while parasellar lesions give more inferior quadrant losses does not greaterThreehaveThree all quadrants quadrantsthan points a complete P<5% with with but all all hemianopia. pointsis points at at least least P<5%. P<5%.Partial Partial Partial three three quadrantthree losses does not Differentials: • Differentials:Papillioedema • •• GlaucomaPapillioedemaOptic nerve (rare) • colobomaOpticnormally nerve at the start generallyof the test testaccompaniedinstrumentinstrument onlythese as points the generallygenerally first. visual by highOften field testtest fixation thesethese loss pointspoints and falsefirst.first. negative.OftenOften Loss of the vertical hemifield respecting the vertical midlinefibres Three from quadrants the ipsilateral with all quadranteye. points at losses least ThreeP<5%.does notquadrants Partial havequadrant three allwith points alllosses points P<5% does at butleast not is P<5%. have allPartial points three P<5% but is •• GlaucomaPapillioedema (rare) • Glaucoma•• PapillioedemacolobomaOptic (rare) nerve • Optic nerveDescription: Diagonal instrumentparacentral generally points showtest these normal instrumentpointsinstrument first. Oftengenerally generally test test these these points points first. first. Often Often greaterquadrant than losses a complete does not hemianopia. quadranthavequadrant all points losses losses P<5% does does• butnot Opticnot ishave have neuritis all all points points P<5% P<5%have• butall but Retinalpoints is is p Optic disc drusen • Titled disc syndrome • normally at the start of• the test only as the visual field Three quadrants with all points at least P<5%. Partial three • Poor supervision • Retinal disease • Papillioedema • Optic nerve instrument generally test these points first. Often quadrant losses does not have all points P<5% but is accompanied by high fixation loss and false negative. greater than a complete hemianopia. • Glaucoma (rare) coloboma • Large peripapillary • Staphyloma Note: Multiple lesions or pathologies may need to be Differentials: considered. atrophy • Megalopapillae • Optic disc drusen • Titled disc syndrome • Inattentive patient • Malingerer • Poor supervision • Retinal disease Chair-side Reference: Visual Field ChairChair--sidesideChairChair Reference:Reference:--sideside Reference:Reference: VisualVisual FieldField VisualVisual FieldField Visual field examination, in particular, standard automated perimetry, remains the most commonly utilised functional assessment. Many ocular and neurological diseases and conditions are known to exhibit distinct visual field loss Visual field examination, in particular, standardChair automated perimetry-side, remains Reference: the most commonly utilised functional Visual assessment. Field Many ocular and neurological diseases and conditions are known to exhibit distinct visual field loss Visual field examination,patterns,Visual in particular, field and examination, thus, standard visual fieldautomatedin particular, testing perimetry may standard therefore, remainsautomated assist the with perimetrymost a differential commonly, remains diagnosis.utilised the most functional The commonly ability assessment. to utilised map the functional Many depth, ocular extent assessment. and and neurological change Many of ocular visualdiseases fieldand and neurologicaldefects conditions should diseases are be known considered and to conditions exhibit in clinical distinct are management known visual to field exhibit decisions.loss distinct The visual more field common loss patterns,Visual field and examination, thus, visualVisualVisual infield particular, f ieldf ieldtesting examination, examination, maystandard therefore inautomatedin particular, particular, assist withperimetry standard standard a differential ,automated automatedremains diagnosis. the perimetryperimetry most The commonly , ability,remains remains to utilised the mapthe most mostthe functional depth,commonly commonly extent assessment. utilisedutilised and change functional functional Many of ocular visual assessment.assessment. and field neurological defects Many Many should ocular ocular diseases be and and considered andneurological neurological conditions in clinical diseases diseases are managementknown and and conditions toconditions exhibit decisions. distinct areare known known The visual moreto to fieldexhibit exhibit common loss distinct distinct visual visual field field loss loss Chair-sidepatterns, and Reference: thus, visualtypespatterns, field of visualtesting and fieldthus, Visualmay defects visualtherefore field and assist Fieldtestingtheir withdifferentials may a differentialtherefore are outlinedassist diagnosis. with below. a The differential ability to diagnosis. map the depth, The ability extent to andmap change the depth, of visual extent field and defects change should of visual be fieldconsidered defects in should clinical be management considered indecisions. clinical management The more common decisions. The more common typespatterns, of visual and thus, field visualdefectspatterns,patterns, field and testing and theirand thus, thus,differentials may visual visual thereforeChair field field are testing assisttestingoutlined with may -may below.side a therefore thereforedifferential assist assist Reference:diagnosis. with with a a differentialThe differential ability todiagnosis. diagnosis. map the The depth,TheVisual ability ability extent to to map mapand the changethe Fielddepth, depth, of visualextent extent field and and defectschange change shouldof of visual visual be field fieldconsidered defects defects inshould should clinical be be managementconsidered considered in in decisions. clinical clinical management management The more common decisions.decisions. The The more more common common types of visual field defectsResultstypes and ofmust visualtheir be differentials fieldinterpreted defects are criticallyand outlined their (reliability differentials below. and are Chairrepeatability) outlined below. and-side in conjunction Reference: with other clinical signs, symptoms Visual and examination Field findings. Visual field examination,Resultstypes in of particular,must visual be field interpreted standard defectstypestypes automated andof criticallyof visual visual their field(reliability differentialsfieldperimetry defects defects ,and remains and areand repeatability) outlinedtheir their the differentials differentials most below. andcommonly in are areconjunction outlined outlinedutilised functionalbelow. withbelow. other assessment. clinical signs, Many symptoms ocular and neurologicalexamination diseasesfindings. and conditions are known to exhibit distinct visual field loss Results must be interpretedResults critically must be (reliability interpreted and criticallyrepeatability) (reliability and inand conjunction repeatability) with and other in conjunctionclinical signs, with symptoms other clinical and examination signs, symptoms findings. and examination findings. patterns, and thus, visualResults field must testing be interpreted may thereforeResultsResults critically must must assist be be (reliabilitywith interpreted interpreted a differential and critically critically repeatability) diagnosis. (reliability (reliability The and abilityand inand conjunction repeatability) repeatability) to map the with depth, and and other in in extent conjunction conjunction clinical and signs, change withwith symptoms other ofother visual clinical clinical andfield examination signs, defectssigns, symptoms symptoms should findings. be and andconsidered examination examination in clinical findings.findings. management decisions. The more common Visualtypes field of visualexamination, field defects in particular, and their standarddifferentialsVertical automated are Field outlined perimetryLoss below. Pattern, remains the most commonly utilised functional assessment.Centrocecal Many ocular and neurological diseases and conditions are known to exhibitNasal distinct Step visual field loss Visual field examination,Vertical Field in particular,Visual Loss f ieldPattern standard examination, automated in particular, perimetry, standard remains automated the most perimetry commonly-utilised, remainsCentrocecal the most commonly Centrocecalutilised functional assessment. Many ocular and neurologicalNasal diseasesNasal Step Step and conditions are known to exhibit distinct visual field loss patterns,Results and must thus, be interpreted visual field criticallytesting may (reliability thereforeVertical and assistrepeatability) Field with Loss a differential Patternand in conjunction diagnosis. with The other ability clinical to map signs, the symptoms depth, extent and examinationand change offindings. visual field defects should be considered in clinical management decisions. The more common functional assessment.VerticalVertical FieldManyField patterns,ocular LossLoss and PatternPattern andVertical neurological thus, visual Field diseases field Loss testing Patternand conditionsmay therefore are assistknown with to exhibita differential distinctCentrocecal Centrocecal diagnosis. The ability to Centrocecalmap the depth, extent and change of visual field defects shouldNasalNasal be considered StepStep in clinicalNasal management Step decisions. The more common types of visual fieldChair defects and their-side differentialsVerticallyVertical Reference: are oriented outlinedField Loss field below. defectsPattern should always Visual raise the suspicion Fieldof pathologies on the Centrocecal Description:Description: Field Field loss lossextending extending from blindspot to NasalDescription: Step Field loss respectingDescription: Field loss respecting the nasal horizontal visual field lossVertically patterns, oriented andtypes thus, field of visual defects visual field fieldshould defectstesting always and mayraise their therefore the differentials suspicion assist of arewithpathologies outlined a differential onbelow. the diagnosis. Description: Field loss extendingfrom blindspot from to blindspot fixation. toMust theDescription: nasal horizontal Field midline loss withrespecting the nasal horizontal Results must be interpretedVertically critically oriented (reliability field defectsvisualVertically and pathwayshould repeatability) oriented always beyond field raise the anddefects theretina, in suspicion conjunctionshould particularly ofalways pathologies ifwith raiseit respects other the on suspicion the theclinical vertical of signs, pathologies midline. symptoms on the and examinationDescription: findings. Field loss extendingfixation.Description: from Must blindspotFieldinclude loss fixation toextending and fromdoes notblindspot obey to Description: Field loss respectingmidlineDescription: withthe nasal at Field least horizontal loss 1 abnormal respecting point the nasaloutside horizontal 15⁰. No Vertical Field Lossvisual VerticallyPattern pathway oriented beyondResults field the mustdefectsVerticallyVertically retina, be shouldinterpreted particularly oriented oriented always field criticallyfield ifraise it defects respectsdefects the (reliability suspicion should should the vertical always alwaysandof pathologies Centrocecalrepeatability) midline. raise raise the the onsuspicion suspicion the and in of conjunctionof pathologies pathologies with on on the otherthe clinical signs,fixation.Description: symptoms Must Field include and loss examination fixationextendingincludeDescription:Description: and fixationNasal from doesfindings. Field FieldblindspotStepandnot doeslossobey loss extendingnot extending to from from blindspot blindspot to to atmidlineDescription: least 1 abnormal with atField pointleast loss outside 1 abnormalrespectingDescription:Description: point the nasal Field outsideField horizontalloss loss 15⁰ respecting respecting. No the the nasal nasal horizontal horizontal visual pathway beyond the visual retina, pathway particularly beyond if it therespects retina, the particularly vertical midline. if it respects the vertical midline. fixation. Must include fixationhorizontalfixation. and does Mustmidline. not include obeyUsually fixation due toand damage does not of obeythe midline with at least 1 abnormalmoremidline than point with 1 point outside at least may 15⁰1 beabnormal. Noon the temporalpoint outside side. 15⁰ . No The ability to map visual the pathway depth, beyond extent theandvisual retina, change pathway particularly of visual beyond iffield it the respects retina,defects the particularly should vertical be midline. ifconsidered it respects thein clinicalvertical midline. horizontalfixation. Must midline. include Usually fixationobeyfixation. due horizontal and to damage doesMust midline. notinclude of obey the fixation and does not obey 15⁰.moremidline No morethan with than 1 pointat 1 leastpoint may may1 abnormalbe midlineon the pointtemporal with outsideat least side. 15⁰1 abnormal. No point outside 15⁰. No Differentials:visual pathway beyond the retina, particularly if it respects the vertical midline. papillomacularfixation.horizontal Must midline. include bundle. Usually fixation due and to doesdamage not ofobey the midlinemore than with 1 at point least may 1 abnormal be on the point temporal outside side. 15⁰ . No Visual field examination, in particular, standard automatedVertically managementperimetry orientedChair ,field remains decisions. defects the should most-side always commonly raise the utilised Reference:suspicion functional of pathologies assessment. on the Many Visual ocular and neurological Field Description:diseases and Field conditions loss extendingpapillomacularhorizontal horizontalare knownfrom midline.midline. blindspot to bundle. exhibit UsuallyUsually to Usuallydistinct duedue due toto visual damage damageto damage field ofof of thethe lossthe Description: Field loss respectingbe moremore on thethe thanthan temporalnasal 11 pointhorizontalpoint side. maymay bebe onon thethe temporaltemporal side.side. Vertical Field Loss PatternDifferentials: Vertical Unilateral Field Loss: Pattern Centrocecal horizontalhorizontalNasal midline. midline. Step Usually Usually due due to to damage damage of of the the Differentials:moremore than than 1 1 point point may may be be on on the the temporal temporal side. side. patterns, and thus, visual field testing may therefore assist with a differentialDifferentials: diagnosis. The abilityDifferentials: to map the depth, extent and change of visual field defects should Centrocecalbe considered in clinicalpapillomacular management bundle. decisions. papillomacularpapillomacular The bundle.more bundle. common Nasal Step Differentials: visual pathway beyond UnilateraltheDifferentials: retina,: particularly if it respectsDifferentials: the vertical midline. fixation. Must include fixation papillomacular and does not bundle. obey papillomacularpapillomacular bundle. bundle. midline with at least 1 abnormalDifferentials: point outside 15⁰. No The more common types of visual field•Differentials: UnilateraldefectsRetinal and: disease their differentials are outlined below. Results must be Differentials:Differentials: • Differentials:Glaucoma Differentials:• Glaucoma • Optic neuritis types of visual field defects and their differentials are outlined below. •UnilateralUnilateralRetinal:: disease horizontal midline. Usually Differentials:due to damage of the more than 1 point may be on theDifferentials:• temporalGlaucoma side. Differentials:• Optic neuritis Vertically oriented field defects should alwaysVertically raise oriented•Unilateral Unilateralthe Presuspicion -fieldchiasmal: : defects of pathologiesor should anterior always onchiasmal theraise the lesion suspicion (e.g. ofcompressive pathologies lesionson the ) Description: Field loss extendingDescription: from blindspot Field loss to• extending Optic• Opticneuritis from neuritis blindspot to • NAION/AIONDescription: Field loss Description:respecting• Papilloedema theField nasal loss respectinghorizontalDifferentials: •the nasalPapilloedema horizontal • High myopia Differentials:interpreted critically• Retinal (reliability disease and repeatability)• Retinal anddisease in conjunction with other clinical signs, symptoms papillomacular bundle. Differentials:Differentials: Differentials: •• GlaucomaGlaucoma ••• GlaucomaOpticOptic neuritisneuritis • Optic neuritis VisualResults field must examination, be interpreted in particular, critically (reliabilitystandard automatedand repeatability) perimetry and, inremains conjunction•• PreRetinal the-chiasmal mostdisease withvisual orcommonly other anterior pathway •clinical• chiasmalbeyond RetinalRetinalutilised signs, thedisease diseaselesion functional retina,symptoms (e.g. particularly compressive assessment.and examinationif it respects lesions Many the) findings. vertical ocular midline. and neurological diseases and conditions• fixation.areOptic known neuritisMust includeto exhibit •fixationDifferentials: Differentials:Cilioretinal• distinct andNAION/AION doesartery visual not occlusion obey field loss midline• Optic• with Papilloedemanerve at least drusen 1 abnormal point•••• OpticGlaucomaoutsideGlaucomaHigh nerve myopia 15⁰ . Nodrusen ••• RetinalOpticOptic neuritis neuritis disease visualUnilateral pathway beyond the• retina,Pre- chiasmalparticularly or ifanterior it respects• chiasmal Pre the-chiasmal vertical lesion or (e.g.midline. anterior compressive chiasmal lesions lesion) (e.g. compressive lesions) fixation. Must include fixation• andOptic does neuritis not obey • •• CilioretinalOpticNAION/AION neuritis artery • • MacularNAION/AIONDifferentials:midline disease with at least 1 abnormal• Papilloedema point outside 15⁰. No•• PapilloedemaHigh myopia • High myopia and: examination• findings. Pre-chiasmal or anterior• chiasmalPre-chiasmal lesion or (e.g. anterior compressive chiasmal lesions lesion) (e.g. compressive lesions) •• horizontalCilioretinalOptic neuritis midline. artery Usually • NAION/AION••• dueOptic MaculartoNAION/AION damage neuritis disease of the • NAION/AION more• Optic ••than OpticPapilloedemaneuritis1 point nerve may bedrusen on the •temporal••• PapilloedemaPapilloedemaRetinalHigh side. myopia disease •• HighHigh myopia myopia patterns, and thus, visual field testing may therefore assist with a differential diagnosis. The abilityBilateral• toPre map- chiasmal(homonymous): the depth,or anterior extent chiasmal and changelesion (e.g. of compressivevisual field lesionsdefects) shouldhorizontal be midline.considered Usually in clinicaldue to damage management of the decisions.•• occlusionOpticCilioretinal neuritisThe more artery common ••• RetinalNAION/AIONMacular more disease disease than 1 point may be on• theOptic temporal nerve side.drusen •• OpticRetinal nerve disease drusen • Retinal disease • Retinal disease Differentials: Differentials: •• papillomacularocclusionCilioretinalCilioretinal artery arterybundle. • Macular•• RetinalMacular Maculardisease disease diseasedisease • Glaucoma • High• Optic myopiaOptic neuritis nerve drusen • Retinal disease types of visual field defects and their differentials areDifferentials: outlined below. Bilateral (homonymous): • Post -chiasmal lesion (e.g. compressive lesions, stroke, injuries) papillomacular bundle. ••• CilioretinalCilioretinal artery artery •• MacularMacular disease disease •• OpticOptic nerve nerve drusen drusen •• RetinalRetinal disease disease Vertical Field Loss Pattern • Pre-chiasmal or anteriorBilateralBilateral chiasmal (homonymous):(homonymous):Centrocecal lesionUnilateral (e.g. : Bilateralcompressive (homonymous): lesions) Nasal• Optic Step neuritis • NAION/AIONocclusionocclusion • Retinal•• occlusionRetinalRetinaldisease diseasedisease • Retinal• Papilloedemadisease Differentials:• RetinalHigh diseasemyopia Unilateral: • Post-chiasmal lesion Bilateral(e.g.Bilateral compressive (homonymous): (homonymous): lesions, stroke, injuries) occlusionocclusion •• RetinalRetinalDifferentials: disease disease Results must be interpreted critically (reliability and repeatability) and in •conjunctionPost-chiasmal with• lesion Retinalother (e.g. •diseaseclinical compressivePost -signs,chiasmal symptoms lesions, lesion stroke,(e.g. and compressive injuries)examination lesions, findings. stroke, injuries) • Cilioretinal artery • Differentials:Macular disease • Optic nerve drusen •• GlaucomaRetinal disease • Optic neuritis • Post-chiasmal lesion •(e.g.• Post compressivePost-chiasmal-chiasmal lesions,lesion lesion (e.g. (e.g.stroke, compressive compressive injuries) lesions,lesions, stroke, stroke, injuries) injuries) Altitudinal Glaucoma Arcuate Optic neuritis Vertically oriented field defects should always raise the suspicion• BilateralRetinal of pathologies (homonymous):disease on the • Pre-chiasmalBilateral or ( banterioritemporalDescription: chiasmal/binasal lesion Field): (e.g.loss extendingcompressive from lesions blindspot) to Differentials:occlusion •Description:Retinal• Optic disease Field neuritis loss respecting• theNAION/AION nasal horizontal • • Papilloedema• • High myopia Vertical FieldBilateral Loss (bitemporal Pattern/binasal): Altitudinal Altitudinal ArcuateArcuate visual pathway beyond the retina, particularly if it respects• the• Pre verticalPost-chiasmal-chiasmal midline. or anterior lesion Bilateral (e.g. chiasmal compressive (bitemporal lesion (e.g.lesions, /binasal compressive• Bilateral stroke,):Chiasmal injuries)(b itemporallesions lesionsfixation. ) (pituitary/ Mustbinasal include): adenoma, fixation meningioma, and does not parasellar obey carotidAltitudinal artery• Optic neuritis Altitudinalmidline• • NAION/AION withCilioretinal at least artery 1 abnormal • pointMacular outside disease 15⁰ . No Arcuate• Papilloedema Arcuate• Optic• Highnerve myopia drusen • Retinal disease •BilateralChiasmal (bitemporal lesions /(pituitarybinasalBilateralBilateral): adenoma, ( b(bitemporalitemporal meningioma,//binasalbinasal): ) :parasellar carotid artery Altitudinal AltitudinalAltitudinal Arcuate ArcuateArcuate Vertical Field Loss Pattern Vertically-oriented• fieldChiasmal defectsCentrocecal lesionsBilateral should (pituitary (homonymous): always• aneurysm, Chiasmaladenoma, raise the horizontal lesionsmeningioma, meningioma,suspicion (pituitary midline. of craniopharyngioma pathologiesparasellar adenoma,Usually duecarotid on meningioma, tothe damage ,arteryvisual glioma) ofpathway parasellar the beyond carotid •arteryNasalCilioretinal Step artery more• Macularthanocclusion 1 point disease may Description:be on •the temporalRetinal Field disease loss side. that respects the •horizontalOptic nerve drusen • Retinal disease Description: Field loss extending from the blind spot to • aneurysm,Chiasmal lesions meningioma, (pituitary• craniopharyngiomaChiasmalChiasmal adenoma, lesions lesions meningioma, (pituitary (pituitary, glioma) parasellar adenoma, adenoma, carotid meningioma, meningioma, artery parasellar parasellar carotid carotid artery artery Description: Field loss thatDescription: respects Field the loss horizontal Description:Description: Field loss Field extending loss fromextending from the blind spot to Differentials: BilateralBilateral (homonymous):the (b retina,itemporal particularly/binasal aneurysm,): if it respects meningioma,• Post the-chiasmal ••vertical craniopharyngiomaTiltedaneurysm, lesion midline.disc (e.g.papillomacular meningioma, compressive, glioma) bundle. lesions,craniopharyngioma stroke, Altitudinalinjuries), glioma) occlusion Description: • Retinal Field disease loss thatmidline.Description: respectsArcuate the Field horizontal loss that respects the horizontal Description: Field loss extendingtheDescription: nasal from field the Fieldwith blind lossat leastspot extending oneto point from outside the blind 15⁰ spot to • Tiltedaneurysm, disc meningioma, craniopharyngiomaaneurysm, meningioma,, glioma) craniopharyngioma , glioma) midline.Description: Field loss thatthatDescription: respects the the horizontalField horizontal loss that respects the horizontal the blindtheDescription: spotnasal to thefield nasal Field with field loss at leastwithextending atDescription: one point from outside theField blind loss 15 spot⁰extending to from the blind spot to VerticallyUnilateral oriented: field defects should always raise the suspicion• Post of-chiasmal pathologies lesion on (e.g.the compressive lesions, stroke,aneurysm, injuries) meningioma,Description: Fieldcraniopharyngioma loss extending ,from glioma) blindspot to Differentials:Description: Field loss Description:midline. respecting Field the lossnasal that horizontal respects the horizontal nasallyDescription:the nasal and field at Field least with loss one at extending leastabnormal one pointfrom point theoutside temporally. blind 15 spot⁰ to • Chiasmal lesions (pituitary•• TiltedTilted adenoma, discdisc meningioma,Vertical• Tiltedparasellar field disc loss carotidcan be arteryclassified into the following midline.midline. midline. least nasallytheonethe pointnasalnasal and outside fieldfield at leastwith15⁰with nasally oneatat leastleast andabnormal oneone pointpoint point outsideoutside temporally. 1515⁰⁰ visual pathway beyond the retina, particularly if it respects the vertical midline. Vertical field lossBilateral can be ( classifiedb•itemporal• TiltedTilted into/binasal disc disc theDifferentials: fixation. ) :following Must include fixation and does not obey Altitudinal • midlineGlaucoma with at leastDifferentials:midline.midline. 1 abnormal• Optic pointneuritis outside 15⁰. NoArcuate thethe nasal nasal field field with with at at least least one one point point outside outside 15 15⁰⁰ • Retinal disease aneurysm, meningioma, craniopharyngioma,patterns: glioma) Description: Field loss that respects the horizontal Differentials: Description: Field loss extendingat leastnasally one from abnormal and the atblind pointleast spot temporally. one to abnormal nasally andpoint at temporally. least one abnormal point temporally. VerticalVertical fieldfield lossloss• cancanChiasmal bebe classifiedclassifiedVertical lesions intointofield (pituitary the theloss followingfollowing can adenoma, be classified meningioma, into the parasellar following carotid artery Differentials: nasally and at least one abnormalnasallynasally and and point at at least temporally.least one one abnormal abnormal point point temporally. temporally. • Pre-chiasmal or anterior chiasmal lesion (e.g. compressiveBilateral• lesionsTilted Differentials(bitemporal) disc /binasalpatterns:): 1.VerticalVertical Vertical field field Step: loss loss• horizontal can canOptic be be classified classified neuritismidline. into intoUsually the the• followingdue followingAltitudinalNAION/AION to damage of the midline. Differentials:• morePapilloedema than 1 point • may Differentials:Branch• •beBranch retinalonHighArcuate the retinalmyopia artery/ temporal side.• Advancedthe nasal glaucoma field with at leastDifferentials: one point outside 15⁰ Differentials: patterns:patterns: aneurysm,patterns: meningioma, craniopharyngioma, glioma) Differentials:• Description:Branch retinal Field loss Differentials: Differentials:that• respectsAdvanced the horizontal glaucoma Description:Differentials: Field loss extending from the blind spot to Differentials: • Chiasmal lesions (pituitary1. Vertical adenoma, Step: meningioma,patterns:patterns: parasellar carotid•papillomacularCilioretinal artery bundle.artery • Macular disease • • Branch Optic retinalnerve drusen vein •• • occlusionartery/veinBranchAdvancedRetinal retinal disease occlusionglaucoma • • CorticalAdvancednasally disease and glaucoma at least(if one abnormal• GlaucomaDifferentials: point temporally. Differentials:• Glaucoma • High myopia Vertical field loss can be1. classified Vertical Step:into the• followingTiltedGenerally disc1. Vertical respects Step: the vertical midline with at least 2 points • midline.artery/veinBranch retinal occlusion ••• BranchCorticalAdvanced retinal disease glaucoma (if • Advanced glaucoma the nasalDifferentials:• fieldGlaucoma with at least one pointDifferentials:• outsideHigh myopia15 ⁰ UnilateralBilateral: (homonymous): aneurysm,Unilateral: meningioma,Generally1. Vertical craniopharyngioma respects Step: theBilateral vertical, glioma)1.1. Vertical Vertical midline(homonymous): Step: Step: with atocclusion least 2 points Bilateral (bitemporal/binasal):• Retinal disease Differentials:Description: Field loss that respectsDifferentials: the horizontal • NAION/AION•• NAION/AIONBranch retinal • bilateral,Advanced Description: rare) glaucoma Field loss• extending Papilloedema from the blind spotDifferentials: •to PapilloedemaGlaucoma • BranchHigh myopia retinal patterns: Generally respects the verticaloutsideGenerally midline 15⁰ respects of with fixation. at the least vertical 2 points midline with at least 2 points artery/veinartery/vein occlusionocclusion •• artery/veinCorticalCortical diseasedisease occlusion (if(if • Cortical disease (if nasally•• andPapilloedemaGlaucomaGlaucoma at least one abnormal point••• temporally.BranchHighHigh myopiamyopia retinal • • Post-chiasmal lesion (e.g. compressive lesions, stroke, injuries) outsideGenerally 15⁰ respects of fixation.Vertical the verticalfield loss midline can be classified withDifferentials: at leastinto the 2 points following midline.• Branch retinal •• AdvancedNAION/AION• Glaucoma glaucoma • Retinal• Retinalartery/veinartery/vein bilateral,disease• diseaseOptic rare) occlusion occlusion neuritis •• CorticalCorticalDifferentials:the disease diseasenasal field (if (if with at• least Optic •one nerve point drusen outside 15⁰ •••• OpticGlaucomaGlaucoma nerve drusen •• artery/veinHighHigh myopia myopia occlusion • Retinal disease • 1.Tilted Vertical• Retinaldisc Step: disease • Post-chiasmal GenerallyGenerally respectslesion respects the the vertical vertical midline midline• Chiasmal with with lesions at at least least (pituitary 2 2 points points adenoma, meningioma, • Differentials:NAION/AION • NAION/AIONbilateral, rare) bilateral, rare) • Papilloedema •• PapilloedemaBranch retinal • Branch retinal outsideoutside 15⁰15⁰ ofof fixation.fixation.patterns: outside 15⁰ of fixation. •• RetinalNAION/AION disease • Advanced•• NAION/AIONNAION/AION bilateral, glaucoma rare) bilateral,bilateral, rare) rare) • Optic•• neuritisOpticPapilloedema nerve drusen ••• PapilloedemaPapilloedemaartery/veinBranch retinal occlusion • • BranchBranch retinal retinal • Pre -chiasmal or anterior chiasmal lesion (e.g. compressive lesions• Pre-chiasmal) or anterior chiasmal (compressiveoutsideoutside 15⁰ 15⁰ lesions, of of fixation. fixation. • Optic neuritisparasellar carotid• NAION/AIONartery aneurysm, meningioma, artery/vein occlusion •• CorticalRetinal• Papilloedema disease (if • Retinal • High disease myopia • nasallyGlaucoma and at least one abnormal• • HighOptic myopiapoint nerve temporally. drusen • • OpticOpticartery/vein neuritis nerve occlusion drusen • Retinalartery/vein disease occlusion VerticalGenerally field respectsloss can thebe classified vertical midline into the with1. following Vertical at least Step: 2 points • •RetinalBranch disease retinal • Cortical• • Retinal diseaseAdvanced disease(if bilateral, glaucoma rare) •Differentials: High• •myopiaOpticOptic neuritisnerve drusen •• OpticRetinalartery/vein nerve disease drusenocclusion artery/vein occlusion Bilateral (bitemporal/binasal): lesion (compressive lesions) Altitudinalstroke, injuries) • Cilioretinal craniopharyngioma,artery • Macular glioma) disease ArcuateDifferentials:• NAION/AION bilateral,• Optic rare) nerve drusen• Retinal • diseaseRetinal disease • Papilloedema • Branch retinal • Optic nerve drusen artery/vein occlusion patterns:outside 15⁰ of fixation. Generally respects the vertical midline with at least 2 points artery/vein occlusion • Cortical disease (if • Branch• ••Glaucoma retinalOpticOptic artery/vein neuritisneuritis occlusion • High••• myopiaOpticRetinalRetinal neuritis diseasedisease • Retinal disease Bilateral• Chiasmal (homonymous): lesions (pituitary adenoma, meningioma, parasellar carotid artery occlusion • Tilted disc • Retinal disease •• RetinalBranch disease retinal • Advanced glaucoma • Differentials:Optic nerve drusen artery/vein occlusion •• OpticOptic neuritis neuritis •• RetinalRetinal disease disease 1. Vertical Step: outside 15⁰ of fixation. • NAION/AION bilateral, rare) • Retinal• Papilloedema disease • Branch retinal aneurysm, meningioma, craniopharyngioma, glioma) Description: Field loss that respects the horizontal TemporalDescription: Wedge Field loss extending from the blind spot to • Optic neuritis Paracentral• Retinal disease • Post-chiasmal lesion (e.g. compressive lesions, stroke,Generally injuries) respects the vertical midline with at least2. 2 Quadrant:points artery/vein occlusion • • CorticalRetinal disease disease (if • Glaucoma • Optic• Highnerve myopia drusen artery/vein occlusion • Tilted disc midline. Temporal Wedge the nasal field with at least one point outside 15⁰ Paracentral Vertical field loss2. Quadrant: can be classified into the four following patterns: Temporal• NAION/AION Wedge Temporalbilateral, Wedge rare) Paracentral• Papilloedema Paracentral• Optic• Branchneuritis retinal • Retinal disease outside 15⁰ of fixation. 2. Quadrant: Visual2. Quadrant: field loss that respects both the vertical & Temporal Wedge TemporalTemporalnasally Wedge and Wedge at least one abnormal point temporally. ParacentralParacentral Paracentral BilateralVertical ( bfielditemporal loss can/binasal be classified): into the following Visual2. Quadrant: field lossAltitudinal that respects2. 2. Quadrant: Quadrant: both the vertical & •ArcuateRetinal disease Temporal Wedge Description: Small visual field defect temporal• Optic to nerveblind drusenParacentral artery/vein occlusionDescription: A small visual field abnormality not Visual field loss that respectshorizontalVisual both field themidline. loss Differentials:vertical that Suggestive respects& of both neurological the vertical involvement & Description: Small visual field defect temporal to blind Description: A small visual field abnormality not • patterns:Chiasmal lesions (pituitary adenoma, meningioma, parasellar carotid artery horizontalVisual field midline. loss that Suggestive respectsVisual ofboth neurologicalfield the loss vertical that involvement respects & both the verticalTemporal & Wedge spot. Paracentral • Optic neuritis • Retinal disease contiguous to the blind spot and within 15⁰ of fixation. 2. Quadrant:1. Vertical Step ifVisual bilateral. field All loss points that2. Quadrant withinrespects the both quadrant the vertical must be& P<5%. Description:Description: SmallSmall visualvisualDescription: fieldfieldDescription: defectdefect Small temporaltemporal visual Small field visual toto blindblind field defect temporal to blind Description:Description:Description: A small visualAA smallsmall field visualvisual Description: fieldfield abnormalityabnormality A small notnot visual field abnormality not horizontalhorizontal midline.midline. SuggestiveSuggestivehorizontal ofof neurologicalneurological midline.Description:• BranchSuggestiveinvolvementinvolvement retinal Field of neurologicalloss that• respectsAdvanced involvement the glaucomahorizontal Temporal Wedge spot.Differentials:Description: Field loss Description:Description: extending from Small Small the visual visual blind field field spot defect defect Paracentralto temporal temporal to to blind blind contiguous to the blind spot Description:Description: and within A A 15small small⁰ of visual fixation.visual field field abnormality abnormality not not 1. Verticalaneurysm, Step: meningioma, craniopharyngioma, glioma) Visual field loss that respectsif bilateral. both All the points 2.vertical Quadrant: within &Note:horizontal horizontal the Pituitaryquadrant midline. midline. gland must Suggestive Suggestive adenoma be P<5%. of givesof neurological neurological more superior involvement involvement defects spot. defectspot. temporal to blind spot. abnormalitycontiguous not contiguous to the blind to the spot contiguous and within to 15 the⁰ of blind fixation. spot and within 15⁰ of fixation. if bilateral. All points withinif thebilateral. quadrant All points mustartery/vein bewithin P<5%. the occlusion quadrant • mustCortical be P<5%. disease (if Description: Small visual field spot.• defect Glaucoma temporal to blindspot.spot. • High myopia Description: A small visual field contiguous abnormality to notthe blind spotcontiguouscontiguous and within to to the 15the⁰ blind ofblind fixation. spot spot and and within within 15 15⁰⁰ of of fixation. fixation. • GenerallyTilted disc respects the vertical midline with at least 2 points horizontal midline. SuggestiveNote:if bilateral. Pituitary of Generallyneurological All pointsglandVisual respects adenoma within involvementfield iftheif lossbilateral. bilateral. thevertical thatgives quadrant respects Allmore All points pointsmidline. must superior both within withinbe the P<5%. defectsvertical the the quadrant quadrant & must mustVisual be be field P<5%. P<5%. loss that respects both the nasal field with atDifferentials: least one point outside 15⁰ blind spot and within 15⁰ of fixation.Differentials: Note: Pituitary gland adenoma(“pieNote:- ingives -Pituitarythe -moresky”) •gland superiorwhileNAION/AION adenoma parasellar defects gives lesions more give superior morebilateral, inferior defects rare) spot. Differentials: • Description:Papilloedema Small visualDifferentials: field• defectBranch temporal retinal to blind contiguous to the blind spotDescription: andDifferentials: within A 15small⁰ of visual fixation. field abnormality not outside 15⁰ of fixation. if bilateral. All points within(“pieNote: the-in Pituitary- thequadrantmidline-sky”) gland horizontalwith whilemust at adenoma least beparasellar midline. Note:P<5%. 2 points gives Pituitary Suggestive lesions more glandgive superiorof neurologicalmore adenoma defectsinferior givesinvolvement more superiorTemporalthe vertical defects and Wedge horizontal midline. nasally and at least one• abnormalOpticParacentral neuritis point temporally. • Retinal disease • Glaucoma • Optic neuritis Vertical field loss can be classified into the following 2. Quadrant: lossesNote: Pituitary(“pie-on- thegland-ground”). adenoma gives more superior defects Differentials:Differentials:spot. • OpticDifferentials: neuritis Differentials:contiguousDifferentials:Differentials: to the blind spot and withinDifferentials: 15⁰ of fixation. (“pie(“pie--inin--thetheoutside--sky”)sky”) if15⁰ bilateral.whilewhile of fixation. parasellarparasellar All(“pie points-in -lesionslesions thewithin-sky”) Differentials: •thegivegive while quadrant Retinal moremore parasellar inferiorinferior disease must be lesions P<5%. giveSuggestive more inferiorof neurological involvement • • Optic Optic neuritis nerve drusen Differentials:Differentials:• Retinalartery/vein disease occlusion • Glaucoma Differentials:Differentials:• Optic neuritis patterns: VisualNote: field Pituitary loss that gland respects adenomalosses both (“pie gives the-on more vertical-the -superiorground”). & (“pie(“pie defects -in-in-the-the -sky”)-sky”) while while parasellar parasellar lesions lesions give give more more inferior inferior • Optic neuritis • Glaucoma• •• GlaucomaOpticRetinal (rare) neuritis disease (rare) • Retinal disease • Glaucoma• Glaucoma • •• PapilloedemaGlaucomaOptic neuritis • • HighOptic myopia neuritis losseslosses (“pie(“pie--onon--thetheNote:--ground”).ground”). Pituitarylosses gland (“pie adenoma-on-the gives-ground”). more superior defectsif bilateral. All points within the Differentials: •• • GlaucomaOpticOptic neuritis neuritis (rare) • Retinal•••• OpticOptic RetinaldiseaseRetinal neuritis neuritis diseasedisease •• RetinalRetinalDifferentials: disease disease • Papilloedema•• PapilloedemaGlaucoma •••• GlaucomaGlaucomaHighOptic myopia neuritis •• OpticOptic neuritis neuritis 1. Vertical Step: (“pie-in-the-sky”) while parasellar lesions give morelosseslosses inferior (“pie (“pie -on-on-the-the•-ground”).-ground”).Branch retinal • Advanced glaucoma Description: Small visual field• defectDifferentials:GlaucomaDifferentials: temporal (rare) to blind• Glaucoma (rare) Description: A small visualDifferentials:• fieldPapilloedema abnormality not • •• OpticPapilloedemaHigh nerve myopia drusen • High myopia horizontal midline. Suggestive of neurological(“pie -involvementin-the - sky”) while parasellar lesions give more inferiorquadrant must be p < 5%. • Optic neuritis •• RetinalGlaucoma disease (rare) • Glaucoma (rare) • Glaucoma • •Optic•• Optic nerveOpticPapilloedema neuritis drusen nerve drusen •• PapilloedemaHigh myopia • High myopia losses (“pie-on-the-ground”). artery/vein occlusion • Cortical disease (if spot. • • OpticGlaucoma neuritis • • GlaucomaRetinal• High disease(rare) myopia contiguous to the blind• spotGlaucoma and within 15⁰ of •fixation.Optic•• PapilloedemaneuritisOptic nerve drusen • High myopia Generally respects the vertical midline with at least 2 pointsif bilateral. All points within the quadrant lossesmust be(“pie P<5%.3.- on Hemianopia-the -ground”).: Note: Pituitary gland adenoma gives • Glaucoma (rare) • Papilloedema • •Optic•• High neuritisOpticOptic myopia nervenerve drusendrusen 3. Hemianopia: • NAION/AION bilateral, rare) • GlaucomaPapilloedema (rare) • Branch retinal Papilloedema High•• myopiaOpticOptic nerve nerve drusen drusen outside 15⁰ of fixation. Note: Pituitary gland adenoma gives Temporalmore superior WedgeLoss defects of the vertical hemifield respecting the morevertical superior midline defects (‘pie-in-the-Paracentral • •• High myopia • 2. Quadrant: 3.3. HemianopiaHemianopia:: 3. Hemianopia: Optic nerve drusen artery/vein occlusion • Differentials:Optic nerve drusen (“pie-in-the-sky”) while parasellarLoss of the lesions vertical give hemifield moreeither3. 3.inferior Hemianopia Hemianopia respecting partially :theor : •completely. verticalRetinal midline disease sky’) while parasellar lesions give moreDifferentials: • • Optic nerve drusen Visual field loss that respects both the vertical & 3. Hemianopia: LossLoss ofof thethe verticalvertical hemifieldhemifieldLoss respectingrespecting of the vertical thethe verticalvertical hemifield midlinemidline respecting the vertical midline Optic neuritis Retinal disease losses (“pie-on-the-ground”).either partially or3. completely.HemianopiaNote:LossLoss: of of Monocular the the vertical verticalDescription: temporal hemifield hemifield hemianopiaSmall respecting respecting visual fieldmaythe the inferiorvertical defectoccurvertical losses if temporalmidline themidline (‘pie-on-the-ground’). to blind • Optic neuritis •Description:Retinal• disease A small visual field abnormality• not • Glaucoma • Optic neuritis horizontal midline. Suggestive of neurological involvement Loss of the vertical hemifieldeithereither respecting partiallypartially oror the completely.completely. verticaleither midline partially or completely. Enlarged Blind Spot Clover Leaf Note: MonocularLoss temporal of thelesioneither verticaleither hemianopia ispartially partially hemifieldmore anterior mayor spot.or respecting completely. completely. occur and if theonly the vertical affecting midline the nasal crossing • Glaucoma (rare) contiguous to the blind spot and within 15⁰ of fixation. • Papilloedema • High myopia if bilateral. All points within the quadrant must be P<5%. either partially or completely.Note:Note: Monocular Monocular temporaltemporalNote: hemianopiahemianopia Monocular maymay temporal occuroccur ifif thethe hemianopia may occur if the Enlarged Blind Spot Clover Leaf lesion is more anterioreither partially andfibresNote:Note: only or from Monocularcompletely.affecting Monocular the ipsilateral the temporal temporal nasal eye.crossing hemianopia hemianopia may may occur occur if if the the Enlarged Blind Spot Enlarged Blind Spot Clover• LeafOptic nerve drusenClover Leaf Note: Pituitary gland adenoma gives more superior defects Note: Monocular temporallesionlesion hemianopia isis moremore anterioranterior may occur andandlesion ifonlyonly the affecting affectingis more anterior thethe nasalnasal and crossingcrossing only affecting the nasal crossing Enlarged Blind SpotEnlargedEnlarged Enlarged Blind Blind Blind Spot Spot Spot CloverClover Leaf Leaf CloverClover Leaf Leaf Description: Diagonal paracentral points show normal 2. Quadrant: fibres from theTemporal ipsilateralNote: Monocular lesionWedgeeye.lesion is temporalis more more anterior anterior Differentials:hemianopia and and mayonly only occur affecting affecting if the the the nasal nasal crossing crossing Paracentral Differentials: Description: Visual field loss involving at least two Description: Diagonal paracentral points show normal (“pie-in-the-sky”) while parasellar lesions give more inferior3. Hemianopialesion is more: anterior fibresand only from affecting the ipsilateral the nasal eye.fibres crossing from the ipsilateral eye. Enlarged Blind Spot Enlarged Blind Spot Description: Visual field loss involvingClover at Leaf least two Clover Leaf or near-normal sensitivity but all other points 3. Hemianopia fibres from the ipsilaterallesion is more fibreseye. anterior from and the only ipsilateral4. affectingThree Quadrantseye. the nasal crossing pointsDescription: contiguous Visual to fieldthe blind loss involvingspot. at least two Description:Description: Diagonal paracentral Diagonal points paracentral Description: points Diagonal show normal paracentral points show normal Visual field loss that respects both the vertical & Loss of the vertical hemifield respecting the vertical fibres midline from the ipsilateral• Optic eye.neuritis • Retinal disease pointsDescription:Description:• Glaucomacontiguous VisualVisual to fieldfield theDescription: loss lossblind• involvinginvolving spot.Optic Visual atneuritisat field leastleast loss twotwo orDescription: near-normal Diagonal sensitivity paracentralDescription: Description:but all other points Diagonal Diagonalpoints show normalparacentral paracentral points points show show normal normal losses (“pie-on-the-ground”). fibres from the ipsilateral eye. fibres from the ipsilateral eye.Description: Small visual field defect temporal to blind Description: A small Description:Description: visual field Visualabnormality Visual field field loss lossnot involving involving at at least least two two show normalor ornear near-normal-normal sensitivity sensitivity butreduced. butor near all other- normalThis ispoints often sensitivity due to but patient all other responding points horizontal midline. Suggestive of neurological involvementeither partially or completely. 4. Three Quadrants:• Glaucoma (rare) Description: Visual field losspoints involving• Description: Papilloedemacontiguous at least Visual totwo the field involving blind pointsloss• spot.involvingat Highleastcontiguous twomyopia at points least to two the blind spot.Description: Diagonal paracentralDescription:reduced.or near points- Diagonalnormal This show is oftensensitivitynormalparacentral due ortobut points patientnear all other-shownormal responding normalpoints sensitivity but all other points points contiguous to the blindpointspoints spot. contiguous contiguous to to the the blind blind spot. spot. all other points reduced. This is often due normallyor near-normal at the startsensitivity of the but test all only other as pointsthe visual field 4. Three Quadrants:Loss of the vertical hemifield spot. Three quadrants with all points at least points contiguous to the blind • spot.pointscontiguousOptic contiguous nerve todrusen thetocontiguous the blind Differentials: blind spot spot. to andthe blindwithin spot. 15 ⁰ of fixation.or near-normal sensitivity orbut near reduced.reduced.all -othernormal pointsThisThis sensitivity isis oftenoften but duedue all toreduced.toother patientpatient points This respondingresponding is often due to patient responding if bilateral. All points within the quadrant must be P<5%. Note: Monocular temporal4. Threehemianopia Quadrants: may occur Three if4. the Three quadrants Quadrants: with all points at least P<5%. Partial three Differentials: to patient normallyresponding atnormally the start at the ofstart the instrumentreduced.reduced. test only This This generallyas is theis often often visual test due due field these to to patient patient points responding responding first. Often Three4. Three quadrants Quadrants:respecting with the allvertical points4. Three midline at least Quadrants: P<5%. Partial three p Enlarged< 5%. Blind Spot Differentials:• PapillioedemaClover Leaf • Opticreduced. nerve This is often due reduced.to patientnormally This responding isat often the start due to of patient thenormally test responding only at as the the start visual of fieldthe test only as the visual field Note:3. Hemianopia Pituitary gland: adenoma gives more superior defectslesion is more anterior and only affecting 4.the Three nasal Quadrants: quadrant4.crossing Three Quadrants: losses does not have all points P<5% but is Differentials:Differentials: Differentials: of the test onlyinstrumentnormally as the visual at generally the field start instrument testof the these normally test pointsonly at as thefirst. the start Oftenvisual of fieldthe test only as the visual field 4. Three Quadrants: ThreeThree quadrantsquadrantseither partially withwith allall or pointspointscompletely.Three atat quadrants leastleast P<5%.P<5%. Differentials:with PartialPartial all points threethree at least P<5%. Partial three • PapillioedemaDifferentials: • PapillioedemaDifferentials:Differentials:• Optic nerve normally at the start of the test accompaniednormallyonlyinstrument as the at visual thegenerally by start fieldhigh offixation test the these test loss only points and as false thefirst. negative.visual Often field (“pie-in-the-sky”) while parasellar lesions give more inferior quadrant losses does not greaterThreehaveThree all quadrants quadrantsthan points a complete P<5% with with but all all hemianopia. pointsis points at at least least P<5%. P<5%.Partial Partial Partial three three quadrantthree losses does not Differentials: • Differentials:Papillioedema • •• GlaucomaPapillioedemaOptic nerve (rare) • colobomaOpticnormally nerve at the start generallyof the test testaccompaniedinstrumentinstrument onlythese as points the generallygenerally first. visual by highOften field testtest fixation thesethese loss pointspoints and falsefirst.first. negative.OftenOften Loss of the vertical hemifield respecting the vertical midlinefibres Three from quadrants the ipsilateral with all quadranteye. points at losses least ThreeP<5%.does notquadrants Partial havequadrant three allwith points alllosses points P<5% does at butleast not is P<5%. have allPartial points three P<5% but is •• GlaucomaPapillioedema (rare) • Glaucoma•• PapillioedemacolobomaOptic (rare) nerve • Optic nerveDescription: Diagonal instrumentparacentral generally points showtest these normal instrumentpointsinstrument first. Oftengenerally generally test test these these points points first. first. Often Often greaterquadrant than losses a complete does not hemianopia. quadranthavequadrant all points losses losses P<5% does does• butnot Opticnot ishave have neuritis all all points points P<5% P<5%have• butall but Retinalpoints is is p

Structure/FunctionStructure/FunctionStructure/Function VisualVisual Pathway PathwayVisual Pathway ClinicalClinical Pearls Pearls The relationship between the retinal nerve fibre layer There are many ocular and neurological conditions that can lead Reliability: TheT herelationship relationship betweenlocation thethe and retinal retinal corresponding nerve nerve fibre visual fibrelayer field layer is complex locationThere due are to manyThere ocular toare field many and defects neurologicalocular with and the neurological following conditions diagram that conditions can showing lead thatthe possibleReliability:can lead to • Unless there is a correlating structural finding, field defects andlocation corresponding and corresponding visualsignificant field visual individual is fieldcomplex is variations complex due to due(Lamparter significant to et to al. field2013). defects Thefield with locationdefects the following ofwith a visual the followingdiagram pathway showing defectdiagram based the showing possibleon the patternthe possible• of field locationUnless there need is a correlating to be repeatable structural before finding, they can field be defectsconsidered to be significant individual followingvariations shows (Lamparter a ‘typical’ et al.structure/function 2013). The locationrelationship of a visualloss. pathway defect based on the pattern of field need to be repeatableclinically significant before they due canto large be considered variability, especially to be in the individualfollowing variations shows a ‘typical’ (Lamparterfor the structure/function right eye et adaptedal. 2013). from relationship The Ferreras following et al. 2008loss. of a visualNote, pathway however, defect that: based on the pattern of field loss. clinicallyNote, significantperiphery. due to large variability, especially in the

showsfor the a ‘typical’ right eye structure/function adapted from Ferreras relationship et al. 2008 for the rightNote, however,however, that:• fieldthat: loss often does not precisely follow the pattern as periphery.• Visual field measurement errors generally result in falsely low outlined below; eye, adapted from Ferreras et al. 2008 • field loss• fieldoften lossdoes oftennot precisely does notfollow precisely the pattern follow asthe pattern• as Visual field measurementsensitivity rather errors than generally falsely high result (Heijl in et falsely al. 1987). low • partial losses or losses that are not entirely symmetrical are outlined below;outlined below sensitivity• ratherFalse thanpositive falsely errors high have (Heijl a greater et al. effect1987). on visual field partial losses or lossescommon. that are not entirely symmetrical are reliability than the fixation loss or false negative errors. • • partial losses or losses that are not entirely symmetrical• areFalse common positive errors have a greater effect on visual field common. reliability• thanIncreased the fixation false negativeloss or false errors negative is correlated errors. with the severity of visual field loss, even with reliable visual field takers (Bengtsson Increased false negative errors is correlated with the severity of • and Heijl 2000). visual field loss, even with reliable visual field takers (Bengtsson and Heijl• 2000).In the presence of severe temporal field defects or micropapillae, blindspot based fixation monitoring is generally • In the presenceineffective, of severe and temporal other forms field of defects fixation or monitoring such as gaze- micropapillaemonitoring, blindspot and based practitioner fixation observation monitoring needs is generally to be used ineffective, andinstead other forms of fixation monitoring such as gaze-

monitoringInterpretation and practitioner observation needs to be used instead• A visual field area with “complete loss” (<0dB for Humphrey’s

Interpretation field) is not necessarily completely blind. A target with a greater • A visual fieldluminance area with or “complete size may still loss” be (<0dB visible for2 Humphrey’s field) is• not necessarilyAs blindspots completely are generally blind. 6 degrees A target in withsize, blindspota greater based fixation monitoring cannot detect fixation loss less than 3 luminance or size may still be visible2 • As blindspotsdegrees are generally (which equates6 degrees to halfin size, the blindspotdistance between based test fixation monitoringlocations cannot for 24/30 detect-2). On fixation the contrary, loss less eye than movement 3 monitoring technique can record fixation loss as small as 1 degrees (which equates to half the distance between test degree. Thus, this should be considered in conjunction with the locations for 24/30-2). On the contrary, eye movement traditional reliability method when interpreting visual field. monitoring technique(Ishiyama et can al. record 2015) fixation loss as small as 1 degree. Thus, this should be considered in conjunction with the Glaucoma: traditional reliability method when interpreting visual field. • In glaucoma, either structural loss or functional loss can occur (Ishiyama et al. 2015) first depending on the sensitivity of the devices used to detect Figure 1. A map showing the relationship between RNFL Glaucoma: the loss (Keltner et al. 2006).

sectors and test points on a 24-2 field test adapted from • In glaucoma,• Central either fieldstructural loss may loss be or seen functional in as many loss as can 50% occur of glaucoma Ferreras et al. IOVS 2008. Figure 2. A diagram showing the visual pathway and field first dependingcases on ( Schieferthe sensitivity et al. 2010) of the and devices thus, a used 10-2 tofield detect or equivalent Figure 1. A map showing the relationship between RNFL loss that may result from different injuries. Grey denotes the loss (Keltnermay beet al.useful. 2006).

Figure 1. A map showing the relationship between RNFL Figurescotoma 2. A diagramon the right showing hand diagrams. the visual pathway and field loss sectors and test points on a 24-2 field test adapted from • Central• field24 loss-2 ismay designed be seen for in glaucoma as many assessment; as 50% of glaucoma if a non- (Zangerl et al Clin Exp Optom 2016) sectorsFerreras and et testal. IOVS points 2008. on a 24-2 field test adapted from Figure 2. A diagramthat may showing result thefrom visual different pathway injuries. and field Grey denotes scotomacases ( Schieferon glaucomatous et al. 2010) defect and thus, is suspected, a 10-2 field utilise or aequivalent 30-2 instead.

Ferreras et al. IOVS 2008. loss that maythe result right from hand different diagrams. injuries. (Zangerl Grey denotes et al Clin Exp Optommay 2017) be useful. scotoma on the right hand diagrams. • 24-2 is designed for glaucoma assessment; if a non- (Zangerl et al Clin Exp Optom 2016) glaucomatous defect is suspected, utilise a 30-2 instead.

Clinical Pearls

Reliability Interpretation Glaucoma

• Unless there is a correlating structural • A visual field area with ‘complete loss’ • In glaucoma, either structural loss finding, field defects need to be repeatable (< 0dB for Humphrey’s field) is not or functional loss can occur first before they can be considered to be necessarily completely blind. A target depending on the sensitivity of the clinically significant due to large variability, with a greater luminance or size may devices used to detect the loss especially in the periphery. still be visible. (Keltner et al. 2006). • Visual field measurement errors generally • As blindspots are generally 6 degrees in • Central field loss may be seen in result in falsely low sensitivity rather than size, blindspot based fixation monitoring as many as 50 per cent of glaucoma falsely high (Heijl et al. 1987). cannot detect fixation loss less than 3 cases (Schiefer et al. 2010) and thus, a • False positive errors have a greater effect degrees (which equates to half the 10-2 field or equivalent may be useful. on visual field reliability than the fixation distance between test locations for loss or false negative errors. • 24-2 is designed for glaucoma 24/30-2). On the contrary, eye movement assessment; if a non-glaucomatous • Increased false negative errors are monitoring technique can record fixation defect is suspected, utilise a correlated with the severity of visual field loss as small as 1 degree. Thus, this loss, even with reliable visual field takers 30-2 instead. should be considered in conjunction (Bengtsson and Heijl 2000). with the traditional reliability method • In the presence of severe temporal field when interpreting visual field. defects or micropapillae, blindspot based (Ishiyama et al. 2015) fixation monitoring is generally ineffective, and other forms of fixation monitoring such as gaze-monitoring and practitioner observation needs to be used instead. Chair-side Reference: Visual Field Reduce visual Chair-Chairside Reference:-side Reference: Visual Visual Field Field

Structure/FunctionStructure/FunctionStructure/Function VisualVisual Pathway PathwayVisual Pathway ClinicalClinical Pearls Pearls The relationship between the retinal nerve fibre layer There are many ocular and neurological conditions that can lead Reliability: field testing time. TheT herelationship relationship betweenlocation thethe and retinal retinal corresponding nerve nerve fibre visual fibrelayer field layer is complex locationThere due are to manyThere ocular toare field many and defects neurologicalocular with and the neurological following conditions diagram that conditions can showing lead thatthe possibleReliability:can lead to • Unless there is a correlating structural finding, field defects andlocation corresponding and corresponding visualsignificant field visual individual is fieldcomplex is variations complex due to due(Lamparter significant to et to al. field2013). defects Thefield with locationdefects the following ofwith a visual the followingdiagram pathway showing defectdiagram based the showing possibleon the patternthe possible• of field locationUnless there need is a correlating to be repeatable structural before finding, they can field be defectsconsidered to be significant individual followingvariations shows (Lamparter a ‘typical’ et al.structure/function 2013). The locationrelationship of a visualloss. pathway defect based on the pattern of field need to be repeatableclinically significant before they due canto large be considered variability, especially to be in the individualfollowing variations shows a ‘typical’ (Lamparterfor the structure/function right eye et adaptedal. 2013). from relationship The Ferreras following et al. 2008loss. of a visualNote, pathway however, defect that: based on the pattern of field loss. clinicallyNote, significantperiphery. due to large variability, especially in the shows a ‘typical’ structure/function relationship for the right however,• fieldthat: loss often does not precisely follow the pattern as ZEISS HFA3 with SITA Faster for the right eye adapted from Ferreras et al. 2008 Note, however, that: periphery.• Visual field measurement errors generally result in falsely low outlined below; eye, adapted from Ferreras et al. 2008 • field loss• fieldoften lossdoes oftennot precisely does notfollow precisely the pattern follow asthe pattern• as Visual field measurementsensitivity rather errors than generally falsely high result (Heijl in et falsely al. 1987). low • partial losses or losses that are not entirely symmetrical are outlined below;outlined below sensitivity• ratherFalse thanpositive falsely errors high have (Heijl a greater et al. effect1987). on visual field partial losses or lossescommon. that are not entirely symmetrical are reliability than the fixation loss or false negative errors. • • partial losses or losses that are not entirely symmetrical• areFalse common positive errors have a greater effect on visual field common. reliability• thanIncreased the fixation false negativeloss or false errors negative is correlated errors. with the severity of visual field loss, even with reliable visual field takers (Bengtsson Increased false negative errors is correlated with the severity of • and Heijl 2000). visual field loss, even with reliable visual field takers (Bengtsson and Heijl• 2000).In the presence of severe temporal field defects or micropapillae, blindspot based fixation monitoring is generally • In the presenceineffective, of severe and temporal other forms field of defects fixation or monitoring such as gaze- micropapillaemonitoring, blindspot and based practitioner fixation observation monitoring needs is generally to be used ineffective, andinstead other forms of fixation monitoring such as gaze- monitoringInterpretation and practitioner observation needs to be used instead• A visual field area with “complete loss” (<0dB for Humphrey’s

Interpretation field) is not necessarily completely blind. A target with a greater • A visual fieldluminance area with or “complete size may still loss” be (<0dB visible for2 Humphrey’s field) is• not necessarilyAs blindspots completely are generally blind. 6 degrees A target in withsize, blindspota greater based fixation monitoring cannot detect fixation loss less than 3 luminance or size may still be visible2 • As blindspotsdegrees are generally (which equates6 degrees to halfin size, the blindspotdistance between based test fixation monitoringlocations cannot for 24/30 detect-2). On fixation the contrary, loss less eye than movement 3 monitoring technique can record fixation loss as small as 1 degrees (which equates to half the distance between test degree. Thus, this should be considered in conjunction with the locations for 24/30-2). On the contrary, eye movement traditional reliability method when interpreting visual field. monitoring technique(Ishiyama et can al. record 2015) fixation loss as small as 1 degree. Thus, this should be considered in conjunction with the Glaucoma: traditional reliability method when interpreting visual field. • In glaucoma, either structural loss or functional loss can occur (Ishiyama et al. 2015) first depending on the sensitivity of the devices used to detect Figure 1. A map showing the relationship between RNFL Glaucoma: the loss (Keltner et al. 2006). sectors and test points on a 24-2 field test adapted from • In glaucoma,• Central either fieldstructural loss may loss be or seen functional in as many loss as can 50% occur of glaucoma Ferreras et al. IOVS 2008. Figure 2. A diagram showing the visual pathway and field first dependingcases on ( Schieferthe sensitivity et al. 2010) of the and devices thus, a used 10-2 tofield detect or equivalent Figure 1. A map showing the relationship between RNFL loss that may result from different injuries. Grey denotes the loss (Keltnermay beet al.useful. 2006).

Figure 1. A map showing the relationship between RNFL Figurescotoma 2. A diagramon the right showing hand diagrams. the visual pathway and field loss sectors and test points on a 24-2 field test adapted from • Central• field24 loss-2 ismay designed be seen for in glaucoma as many assessment; as 50% of glaucoma if a non- (Zangerl et al Clin Exp Optom 2016) sectorsFerreras and et testal. IOVS points 2008. on a 24-2 field test adapted from Figure 2. A diagramthat may showing result thefrom visual different pathway injuries. and field Grey denotes scotomacases ( Schieferon glaucomatous et al. 2010) defect and thus, is// suspected, aRELIABILITY 10-2 field utilise or aequivalent 30-2 instead.

Ferreras et al. IOVS 2008. loss that maythe result right from hand different diagrams. injuries. (Zangerl Grey denotes et al Clin Exp Optommay 2017) be useful. MADE BY ZEISS scotoma on the right hand diagrams. • 24-2 is designed for glaucoma assessment; if a non- (Zangerl et al Clin Exp Optom 2016) glaucomatous defect is suspected, utilise a 30-2 instead.

Clinical Pearls 8 Reliability Interpretation Glaucoma 7 4-8 minutes NEW ZEISS SITA Faster • Unless there is a correlating structural • A visual field area with ‘complete loss’ • In glaucoma, either structural loss 6 finding, field defects need to be repeatable (< 0dB for Humphrey’s field) is not or functional loss can occur first Accelerate your clinic flow before they can be considered to be necessarily completely blind. A target depending on the sensitivity of the 5 2-6 50% clinically significant due to large variability, with a greater luminance or size may devices used to detect the loss minutes Faster Enhance your patient’s experience by reducing especially in the periphery. still be visible. (Keltner et al. 2006). 4 testing time, up to 50% with SITA Faster. • Visual field measurement errors generally • As blindspots are generally 6 degrees in • Central field loss may be seen in result in falsely low sensitivity rather than size, blindspot based fixation monitoring as many as 50 per cent of glaucoma 3 1.5-4 falsely high (Heijl et al. 1987). minutes • Clinically equivalent to SITA Fast and SITA Standard.1 cannot detect fixation loss less than 3 cases (Schiefer et al. 2010) and thus, a 2 • False positive errors have a greater effect degrees (which equates to half the 10-2 field or equivalent may be useful. • Can be immediately adopted and mixed with on visual field reliability than the fixation distance between test locations for loss or false negative errors. • 24-2 is designed for glaucoma 1 other SITA strategies to contribute to GPA reports. 24/30-2). On the contrary, eye movement assessment; if a non-glaucomatous • Increased false negative errors are monitoring technique can record fixation • Same SITA algorithm and normative data as defect is suspected, utilise a Time Ranges (minutes) Test Typical 0 correlated with the severity of visual field loss as small as 1 degree. Thus, this SITA Standard and Fast. loss, even with reliable visual field takers 30-2 instead. SITA SITA SITA should be considered in conjunction (Bengtsson and Heijl 2000). Standard Fast Faster with the traditional reliability method 24-2 24-2 24-2 • In the presence of severe temporal field when interpreting visual field. For more information visit: defects or micropapillae, blindspot based (Ishiyama et al. 2015) fixation monitoring is generally ineffective, www.zeiss.com.au/med and other forms of fixation monitoring ZEISS such as gaze-monitoring and practitioner Ph: 1300 365 470 observation needs to be used instead. [email protected]

1. Based on data from internal validation trials 18 MARCH 2018

Visual Fields From page 13 the significance of these features and associated pass-fail criteria however differ between instruments as well as between associated studies and grading systems.15 Some automated indices, such as mean deviation (MD), pattern standard deviation (PSD) and the Glaucoma Hemifield Test (GHT) may be more conducive to a quick overview of the SAP result, but they are also confounded by subtle sensitivity variations. Therefore, careful examination of each map in the printout is critical (Figure 1; also see Phu et al. 2017 CXO for examples of artefacts seen in VF testing).16

1. Reliability indices

The instrument flags results that are outside of the manufacturer’s limits.

2. Gaze tracker result Figure 2. A 70-year-old Caucasian male with a previous pituitary tumour treated with surgical excision. Cirrus OCT results are shown on top (Ganglion Cell Analysis thickness map). The OCT results display binasal structural loss, which are typical of chiasmal lesions. The HFA Blips above the midline indicate eye 30-2 SITA-Standard results shown at the bottom do not show a typical bitemporal defect movements. Larger blips indicate expected in a patient with a chiasmal lesion. This is because of the visual recovery following bigger movements. Blips below surgical treatment performed in 1995. Note that results have been shown as per typical represent either blinks or tracking visual field analysis (right eye [RE] results on the right and left eye [LE] results on the left). errors.

3. Sensitivity results (in dB) 6. Mean deviation (MD) and pattern significant VF loss may be useful in Careful examination of sensitivity standard deviation (PSD) identifying the locus of structural loss results may reveal subtle changes in (that is: retinal, optic nerve, chiasm the Hill of Vision. The sensitivities MD is the ‘average' amount of or higher cortical areas). We have flagged in the red boxes (33 dB) are depression (with location-specific recently reviewed the applications higher than expected, and thus have weighting). It is typically used for of SAP to different ocular and raised the patient’s Hill of Vision, staging and monitoring glaucoma. neurological diseases,16 and the VF affecting statistical analyses on the PSD is the standard deviation of these Chair-side Reference printed in this deviation maps. depressions and highlights focal issue highlights types of VF defects defects. associated with different diseases. 4. Glaucoma Hemifield Test (GHT) Below, we highlight the continued role 7. Pattern deviation map of SAP in current practice, and offer The GHT states the results of some debates regarding its clinical asymmetry analyses across mirrored This helps highlight patterns of focal efficacy. zones about the horizontal midline. loss. It is typically used for diagnosis It is used by many clinical studies as (p < 5 per cent) and does not highlight SAP vs selective perimetry an index of abnormality. Note that the exact depth of defect, as these are this index uses probability scores, not probability values (see the squares Although it is the current clinical sensitivity results. flagged in this example). standard for functional assessment in glaucoma, SAP is thought to be 5. Visual Field Index (VFI) Tip 1: Automated indices that are used relatively insensitive to loss of early in grading scales and progression visual function in glaucoma, with a This is the percentage of VF loss studies may differ, depending on the poor structure-function relationship in following age correction, calculated instrument. early stages of the disease.17,18 Recent based on the amount of reduction studies have suggested that structural of all locations with a significant VF printouts typically provide a map loss in glaucoma may be detectable depression. Note that this index is not that reports the statistical likelihood of prior to the onset of functional defects typically used in clinical trials as a abnormality (that is: a ‘deviation’ map). on SAP. This is known as ‘pre- diagnostic tool. Examining patterns of statistically- perimetric glaucoma’.19-22 MARCH 2018 19

may have atypical optic nerve head Reported category Structural Functional Both configurations that are more suited to OHTS Medication 50.0% 41.7% 8.3% SAP, rather than OCT testing. (Kass et al 2002) Observation 57.3% 32.6% 10.1% Tip 3: Many studies use different EMGT MD ≥ -6 dB 20.0% 80.0% 0.0% criteria for VF or structural endpoints, (Ohnell et al., 2017) -12 dB ≤ MD < -6 dB 20.3% 79.7% 0.0% and thus need careful consideration when comparing across studies. -16 dB ≤ MD < -12 dB 0.0% 100.0% 0.0%

CNTGS (1998) Treated 11.5% 88.5% 0.0% Retrograde degeneration Untreated 10.7% 89.3% 0.0% As mentioned, studies have suggested EGPS (Miglior et al 2005) All progressors 40.0% 60.0% 0.0% that OCT may be able to detect more abnormalities in early disease Recent studies on Kim et al (2015) 59.7% 16.7% 23.6% when compared to SAP. However, in pre-perimetric glaucoma Jeong et al (2014) 53.7% 26.8% 19.5% retrograde degeneration, the converse may occur; patients may show significant functional loss prior to Table 1. Proportion of patients reaching structural or functional endpoints for glaucoma detectable structural loss using OCT.28 in various major clinical trials. Where possible, different reported categories of patients Studies have also shown that treatment within the trials are also distinguished. of lesions in the higher visual pathway such as tumours at the chiasm may have no or slow ganglion cell recovery Alternative methods of assessing the functional (Table 1).19,20 As a result, it on OCT imaging, but SAP may show VF have been suggested. Some of these is suggested that SAP and OCT may be recovery more quickly (Figure 2).29 have come to be known as ‘selective more clinically useful at different stages perimetry’ as they purportedly test of glaucoma.26 Early in the disease Tip 4: Though structural loss may specific visual functions.23 Such process, OCT may detect subtle changes precede functional loss in many cases techniques include flicker perimetry missed by SAP. When the measurement of disease, there are instances where (available on the Medmont automated floor is reached by the OCT, SAP may be VF examination may detect conversion perimeter), frequency-doubling able to better track disease progression. to disease, progression of disease technology (using the Matrix perimeter) or recovery from disease, prior to and flicker-defined form perimetry Why then do we continue to use SAP appreciable structural changes. (Heidelberg Edge Perimeter). There is in glaucoma assessments? Recent debate regarding their efficacy; initial studies comparing OCT and SAP Future – will we be using SAP? studies showed promise in greater for assessment of glaucomatous detection rates using these instruments progression have shown that each Currently, there is a slew of research compared to SAP, but later studies technique may actually identify being undertaken in structure-function have shown equivocality. Thus, current cases missed by the other. In other relationships in normal and diseased recommendations are that SAP remains words: no one technique identifies the clinical standard.24 all cases perfectly.27 Some patients Continued page 20 Tip 2: SAP remains the clinical standard for assessment of the visual field. Alternative perimeters may be considered adjunctive to the clinical examination.

SAP and OCT: which is more useful? Pre-perimetric glaucoma

There is a common misconception that 25–33 per cent of retinal ganglion cell loss occurs prior to the manifestation of VF defects,18,25 such as in pre-perimetric glaucoma. Actually, the majority of landmark clinical trials more commonly showed detection of progression using SAP (functional) testing (see Table 1). However, these studies were performed prior to spectral domain OCT. More Figure 3. The 24-2 test grid (green) with 54 test locations spaced six degrees apart. Because recent studies on pre-perimetric of the sparse testing density, subtle loss within 10 degrees of fixation may be missed. The glaucoma detected progression in up 10-2 test grid (red) offers a higher test density (two degrees spacing) within the central 20 to four times more glaucoma patients degrees, and may help to detect early defects in the macula. In the future, superimposition or with structural findings compared to modification of test grids may become the norm. 20 MARCH 2018

our perimeters solely with advanced the Early Manifest Glaucoma Trial. Acta imaging devices like OCTs. Ophthalmol Scand 2003; 81: 286-93. Visual Fields 13. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment From page 19 Study: a randomized trial determines Key clinical pearls: that topical ocular hypotensive medication delays or prevents the onset * Carefully examine all aspects of the of primary open-angle glaucoma. Arch eyes. Recent advances in the area VF printout: individual sensitivity Ophthalmol 2002; 120: 701-13. 14. Leske MC, Heijl A, Hyman L, et al. Early include customising functional testing values provide important information Manifest Glaucoma Trial: design and based on the structure of the eye, such that can then be correlated with baseline data. Ophthalmology 1999; 106: as using the fovea-to-disc angle and the automated indices (see Phu et al., 2017 2144-53. 15. Mills RP, Budenz DL, Lee PP, et al. temporal raphe to adjust the orientation CxO for more information). Categorizing the stage of glaucoma from of the VF to match the retinal nerve pre-diagnosis to end-stage disease. Am J fibre layer projections.30 * Describing the VF defect is important Ophthalmol 2006; 141: 24-30. 16. Phu J, Khuu SK, Yapp M, Assaad N, et to localise the likely site of anatomical al. The value of visual field testing in the There have been recent innovations anomaly, in other words: structure- era of advanced imaging: clinical and in the area of adaptive algorithms function analysis (see the CFEH psychophysical perspectives. Clin Exp Optom 2017; 100: 313-332 for increasing the efficiency of SAP Chair-side Reference on Visual Field 17. Malik R, Swanson WH, Garway-Heath testing. A new iteration of the Swedish Interpretation in this issue of Pharma DF. ‘Structure-function relationship’ Interactive Thresholding Algorithm and Zangerl et al., 2017 CxO for more in glaucoma: past thinking and current concepts. Clin Experiment Ophthalmol (SITA) available on the Humphrey information). 2012; 40: 369-80. Field Analyzer (HFA) is SITA Faster, 18. Anderson RS. The psychophysics of which is available on current or new * SAP is the current clinical standard; glaucoma: improving the structure/ function relationship. Prog Retin Eye HFA3 models. Similar advances are other perimetric techniques are Res 2006; 25: 79-97. anticipated to be available in other recommended as adjunctive methods. 19. Jeong JH, Park KH, Jeoung JW, et al. Preperimetric normal tension glaucoma perimetric instruments in the future. study: long-term clinical course and Some algorithms have also been * Combining structural and functional effect of therapeutic lowering of developed to target specific areas of measurements is essential for effective intraocular pressure. Acta Ophthalmol 2014; 92: e185-93. interest to improve the reliability of patient care. 20. Kim KE, Jeoung JW, Kim DM, et al. measurements at scotomata.31 Long-term follow-up in preperimetric 1. Lucy KA, Wollstein G. Structural and open-angle glaucoma: progression rates Functional Evaluations for the Early and associated factors. Am J Ophthalmol Other areas of interest in VF are Detection of Glaucoma. Expert Rev 2015; 159: 160-8 e1-2. also being studied. Specifically for Ophthalmol 2016; 11: 367-76. 21. Kuang TM, Zhang C, Zangwill LM, et al. glaucoma, the central 10 degrees of 2. Wong E, Yoshioka N, Kalloniatis M, Estimating Lead Time Gained by Optical Zangerl B. Cirrus HD-OCT short-term Coherence Tomography in Detecting the VF has been highlighted as an area repeatability of clinical retinal nerve Glaucoma before Development of Visual of interest, as it has a denser testing fiber layer measurements.Optom Vis Sci Field Defects. Ophthalmology 2015; 122: grid (Figure 3).32,33 The far peripheral 2015; 92: 83-8. 2002-2009. 3. Yenice O, Temel A. Evaluation of two 22. Lisboa R, Leite MT, Zangwill LM, et field however is more important for Humphrey perimetry programs: full al. Diagnosing preperimetric glaucoma navigation, and so it is likely that a threshold and SITA standard testing with spectral domain optical coherence combination of peripheral and central strategy for learning effect. Eur J tomography. Ophthalmology 2012; 119: Ophthalmol 2005; 15: 209-12. 2261-2269. VF assessment will become the norm in 4. Gardiner SK, Demirel S, Johnson CA. Is 23. Sakata LM, DeLeon-Ortega J, Girkin the future.34-36 there evidence for continued learning CA. Selective perimetry in glaucoma over multiple years in perimetry? Optom diagnosis. Curr Opin Ophthalmol 2007; Vis Sci 2008; 85: 1043-8. 18: 115-121. Recent commentary has also reminded 5. Johnson CA, Wall M, Thompson HS. 24. Jampel HD, Singh K, Lin SC, et al. us of the precedent nature of current A history of perimetry and visual field Assessment of visual function in 37−40 testing. Optom Vis Sci 2011; 88: E8-15. glaucoma: a report by the American stimulus parameters used in SAP. 6. McLean AJ. Practical Perimetry: Academy of Ophthalmology. Work from our laboratory conducted Construction and Operation of the Ophthalmology 2011; 118: 986-1002. in modifying parameters of the test Tangent Screen. Can Med Assoc J 1937; 25. Kerrigan-Baumrind LA, Quigley HA, et 36: 578-83. al. Number of ganglion cells in glaucoma has shown promise in earlier detection 7. Heijl A, Krakau CE. An automatic eyes compared with threshold visual of VF defects in glaucoma.37,39 In perimeter for glaucoma visual field field tests in the same persons.Invest the future, it may be possible to screening and control. Construction Ophthalmol Vis Sci 2000; 41: 741-748. and clinical cases. Albrecht Von Graefes 26. Medeiros FA, Zangwill LM, Bowd individually tailor stimulus parameters Arch Klin Exp Ophthalmol 1975; 197: C, et al. The structure and function to test different stages of glaucoma from 13-23. relationship in glaucoma: implications diagnosis to end-stage monitoring.37,39 8. Heijl A, Krakau CE. An automatic static for detection of progression and perimeter, design and pilot study. Acta measurement of rates of change. Invest Ophthalmol (Copenh) 1975; 53: 293-310. Ophthalmol Vis Sci 2012; 53: 6939-6946. 9. McKendrick AM. Recent developments 27. Banegas SA, Anton A, Morilla-Grasa Conclusion in perimetry: test stimuli and A, et al. Agreement among spectral- procedures. Clin Exp Optom 2005; 88: domain optical coherence tomography, VF testing is certainly not the most 73-80. standard automated perimetry, and exciting part of the ophthalmic 10. Heijl A, Lindgren G, Olsson J. Normal stereophotography in the detection examination. Although the printout, variability of static perimetric threshold of glaucoma progression. Invest values across the central visual field. Ophthalmol Vis Sci 2015; 56: 1253-1260. procedure and instrument may appear Arch Ophthalmol 1987; 105: 1544-9. 28. Zangerl B, Whatham A, Kim J, Choi A, to be simple, clinicians should be 11. Garway-Heath DF, Crabb DP, Bunce C, et Assaad NN, et al. Reconciling visual vigilant and judicious in its use in al. Latanoprost for open-angle glaucoma field defects and retinal nerve fibre (UKGTS): a randomised, multicentre, layer asymmetric patterns in retrograde practice. Nevertheless, VF testing is placebo-controlled trial. Lancet 2015; degeneration: an extended case series. still central to patient diagnosis and 385: 1295-304. Clin Exp Optom 2017; 100: 214-226. 12. Heijl A, Leske MC, Bengtsson B, et management in clinical practice, al. Early Manifest Glaucoma Trial G. and so it is not yet time to replace Measuring visual field progression in Continued page 21 MARCH 2018 21

Therapeutic News of note

from oxidative damage. Lower life 2016 to June 2017. The list appeared Associate Professor expectancy in Indigenous populations in the December issue of Australian Mark Roth may also play a role, given that Prescriber. increasing age is a key risk factor for BSc(Pharm) BAppSc(Optom) AMD. The cost to the Australian government PGCertOcTher for aflibercept (Eylea) was $261 NEWENCO FAAO OAM In line with data from other Caucasian million, with more than 203,000 populations, AMD remains a leading prescriptions, and $213 million for cause of vision loss in Australia, and ranibizumab (Lucentis) with more with increasing life expectancies, the than 169,000 prescriptions, placing prominence of AMD is projected to the anti-VEGF treatments solidly grow. among the most expensive drugs of the The growing burden of AMD in year. Australia Overall, the study reinforced the Australia will need to increase the importance of regular eye checks for www.nps.org.au/australianprescriber number of low vision rehabilitation those in the at-risk population (anyone services to cope with the projected over 60 years old, particularly with a IVMED-80, an eye drop used for increase in AMD, say the authors of family history of AMD) as well as the keratoconus The Australian National Eye Health need to increase the number of low- Survey. vision rehabilitation services for those The US Food and Drug Administration whose vision will be affected by AMD (FDA) has granted ‘orphan drug In a study published in JAMA in the future. designation’ to IVMED-80, an eye drop Ophthalmology, age-related macular used for cross-linking the cornea to degeneration was attributed as the JAMA Ophthalmol. treat keratoconus. main cause of vision loss in 11.1 per Oct 2017. doi:10.1001/ cent of non-Indigenous Australians jamaophthalmol.2017.4182 IVMED-80 is the first eye-drop, non- and 1.1 per cent of Indigenous surgical, non-laser treatment for Australians. medical crosslinking of the cornea. Lucentis and Eylea in the top ten in It biomechanically strengthens the cost to Australian government The study authors say that it is not cornea through the daily application of clear why the AMD rate for Indigenous Eylea (aflibercept) and Lucentis a non-invasive, proprietary eye-drop. people is so low, but suggest that (ranibizumab) were listed fifth and IVeena Delivery Systems, the US-based people with higher levels of retinal sixth, respectively, in the top 10 pigmentation may be protected subsidised drugs for the year July Continued page 22

Tests in Glaucoma Suspects, Ocular 37. Kalloniatis M, Khuu SK. Equating Hypertensives, and Early Glaucoma. spatial summation in visual field Visual Fields Ophthalmology 2017; 124: 1449-1456. testing reveals greater loss in optic From page 20 33. Traynis I, De Moraes CG, Raza AS, nerve disease. Ophthalmic Physiol Opt et al. Prevalence and nature of early 2016; 36: 439-452. glaucomatous defects in the central 38. Mulholland PJ, Redmond T, Garway- 29. Moon CH, Hwang SC, Ohn YH, et al. 10 degrees of the visual field.JAMA Heath DF, et al. Spatiotemporal The time course of visual field recovery Ophthalmol 2014; 132: 291-297. Summation of Perimetric Stimuli in and changes of retinal ganglion cells 34. Ehrlich AC, Raza AS, Ritch R, et al. Early Glaucoma. Invest Ophthalmol Vis after optic chiasmal decompression. Modifying the Conventional Visual Sci 2015; 56: 6473-6482. Invest Ophthalmol Vis Sci 2011; 52: Field Test Pattern to Improve the 39. Phu J, Khuu SK, Zangerl B, et al. 7966-7973. Detection of Early Glaucomatous A comparison of Goldmann III, V 30. McKendrick AM, Denniss J, Wang YX, Defects in the Central 10 degrees. and spatially equated test stimuli in et al. The Proportion of Individuals Transl Vis Sci Technol 2014; 3: 6. visual field testing: the importance Likely to Benefit from Customized 35. Hood DC, Nguyen M, Ehrlich AC, et of complete and partial spatial Optic Nerve Head Structure-Function al. A Test of a Model of Glaucomatous summation. Ophthalmic Physiol Opt Mapping. Ophthalmology 2017; 124: Damage of the Macula With High- 2017; 37: 160-176. 554-561. Density Perimetry: Implications for the 40. Redmond T, Garway-Heath DF, 31. Chong LX, Turpin A, McKendrick AM. Locations of Visual Field Test Points. Zlatkova MB, et al. Sensitivity loss in Assessing the GOANNA Visual Field Transl Vis Sci Technol 2014; 3: 5. early glaucoma can be mapped to an Algorithm Using Artificial Scotoma 36. Monter VM, Crabb DP, Artes PH. enlargement of the area of complete Generation on Human Observers. Transl Reclaiming the Periphery: Automated spatial summation. Invest Ophthalmol Vis Sci Technol 2016; 5: 1. Kinetic Perimetry for Measuring Vis Sci 2010; 51: 6540-6548. 32. De Moraes CG, Hood DC, Thenappan Peripheral Visual Fields in Patients A, et al. 24-2 Visual Fields Miss With Glaucoma. Invest Ophthalmol Vis Central Defects Shown on 10-2 Sci 2017; 58: 868-875. 22 MARCH 2018

Duke University in the US say they 1, and 61 patients were moderate and News may have found a way to disrupt or severe and made up group 2. even reverse the growing prevalence From page 21 of antibiotic resistance, without Corneal hysteresis was lower in antibiotics. group 2, according to researchers. They found a significant difference in biopharmaceutical company behind Writing in the journal Nature corneal hysteresis between the OSAS the drug, said it will begin clinical Communications, the scientists say groups. ‘This may be another link development of IVMED-80 in 2018. there are drugs that can both stop the between OSAS and the development sharing of genes and decrease the rate of glaucoma’ they wrote. ‘Further The Orphan Drug Act provides at which they are passed on through studies are indicated to determine the incentives for companies to develop reproduction. significance of this connection.’ products for rare diseases affecting fewer than 200,000 people. Incentives The scientists maintain that reducing The results of this study suggest that may include tax credits related to the use of antibiotics will not be although obstructive sleep apnoea clinical trial expenses, FDA assistance enough because of conjugation, a can’t be considered a predictor of in clinical trial design and potential process by which bacteria quickly glaucoma, patients with the condition market exclusivity for seven years share the ability to fight antibiotics by should be monitored for the earliest following approval. swapping genes between species and signs of the disease. then maintain their resistance even in www.iveenamed.com the absence of antibiotics. Optometry and Vision Science. Oct 2017. doi: 10.1097/ One drug, ‘a benign natural product’, OPX.0000000000001117 Adjustable post-operative IOL to is known to inhibit conjugation, improve vision approved by FDA while the other, an FDA-approved Fewer signs of inflammation with The US Food and Drug Administration antipsychotic, encourages resistance daily disposable contact lenses (FDA) has approved the RxSight Light genes to be lost. Adjustable Lens (RxLAL) and the Light Higher ocular inflammatory responses Delivery Device (LDD) for patients ‘We found that without the presence were found in reusable contact lens with pre-existing astigmatism of ≥ 0.75 of antibiotics, we could reverse the wearers than in daily disposable (DD) D undergoing cataract surgery. bacteria’s resistance in four of the contact lens (CL) wearers. pathogens we tested and could stop According to a press release by the it from spreading in the rest’, the Researchers compared the FDA, RxLAL is the first medical researchers wrote. concentrations and ratios of tear device system that can make small cytokines and changes to conjunctival adjustments to the artificial lens’ The next step for the team is to cell morphology in healthy habitual power after cataract surgery so that the identify additional chemicals that can daily disposable (DD) and reusable soft patient will have better vision when fill these roles more effectively. contact lens wearers. not using glasses. Nature Communications. Nov 2017. Thirty-six established daily CL RxLAL is made of a unique material doi: 10.1038/s41467-017-01532-1 wearers, including 14 DD and 24 that reacts to UV light, which is reusable wearers, were enrolled. delivered by the LDD, two-to-three Symptoms and ocular surface integrity Measuring IOP in patients with weeks after surgery. Patients receive were evaluated. three or four light treatments over obstructive sleep apnoea a period of one-to-two weeks, each Another link between obstructive The study found that reusable soft lasting about 40–150 seconds, sleep apnoea syndrome (OSAS) and contact lens wear was associated with depending upon the amount of glaucoma may have been discovered higher concentrations of tear cytokines, adjustment needed. The patient in a recent study on corneal hysteresis more conjunctival staining and greater must wear special eyeglasses for (CH). conjunctival epithelial metaplasia UV protection from the time of the compared with daily disposable cataract surgery to the end of the light Researchers at the University contact lens wear. treatments to protect the new lens from Malaya Medical Centre, Kuala UV light in the environment. Lumpur conducted a cross-sectional, Although the results suggest that observational study to look at the reduction in pre-inflammatory changes The device is intended for patients association between CH and severity might contribute to the improvement who have astigmatism (in the cornea) of OSAS, and whether CH could be in comfort after switching to daily before surgery and who do not have another link between OSAS and the disposable lenses, the study authors macular diseases. development of glaucoma. emphasised the need for further studies to evaluate factors affecting eye www.rxsight.com Measuring central corneal thickness discomfort and inflammation—not just using biometry, corneal hysteresis contact lens replacement schedule, but using ocular response analysis, IOP and also lens material and design. Non-antibiotic drugs for antibiotic Humphrey visual field, a total of 56 resistance? patients were classified as normal and Optometry and Vision Science. A team of biomedical engineers from mild categories and placed into group Nov 2017. doi: 10.1097/ OPX.0000000000001129 MARCH 2018 23

Infantile nystagmus syndrome

nystagmus in a jerk pattern which improvement of two-to-three lines of Leah Batterham was present in all directions of gaze. visual acuity and a reduction of both the BOptom/BSci (Hons) Nystagmus was at lowest intensity on nystagmus and the head turn. A three- right gaze and he had a constant left month review was arranged. head turn of approximately 20 degrees. UNSW Differentials He also exhibited convergence damping, full eye movements and normal pupil • Sensory deprivation: including reactions. Best corrected distance visual cataracts, media opacities, optic nerve acuity was 6/18 in each eye with no and retinal disease, Leber’s congenital Infantile nystagmus syndrome (INS) head turn and a spectacle prescription of amaurosis, achromatopsia, and any is a rare condition which presents as R -0.75/-0.25 x 170 L -1.00. Interestingly, abnormality of the afferent visual involuntary, oscillatory, conjugate eye with the left head turn the visual acuity pathway. However, ocular health movements along the horizontal plane improved to 6/12. In this position he was normal. VEP and ERG should be with an age of onset of two to four achieved N5 reading vision and reduced performed to confirm retinal dystrophy months.1 Patients usually have reduced nystagmus. He showed binocularity with or Leber’s if suspected. visual acuity with no other contributing no strabismus and normal stereopsis. eye health issues, and while it is a Colour vision with Ishihara and • Structural brain disease, including genetic condition, there is not always a confrontation visual fields were normal. lesions of the brainstem or cerebellum: family history. this was ruled out by MRI and CT scan. Ocular health was unremarkable. To INS patients may have a detectable rule out structural brain disorders, the • Toxic-induced nystagmus: history- ‘null point,’ a direction of gaze where patient was referred to a paediatric taking should reveal drug use or illness. nystagmus has lowest intensity, and ophthalmologist for MRI and CT scan when this is not in primary gaze the of the optic nerve, chiasm and brain • Opsoclonus: important to patient may adopt an anomalous with normal contrast, which came diagnose due to the association head turn to access this position of back normal. During the consultation with paraneoplastic syndrome and gaze most of the time. Some patients at the paediatric ophthalmologist, they encephalitis. Tested by MRI and exhibit less nystagmus on convergence, measured his IOP under sedation, which toxicology screen, blood testing for a phenomenon called ‘convergence gave a reading of 13 mmHg each eye. metabolic and serum electrolytes and damping’. The patient also had a full systemic paraneoplastic antibodies. However, check by his family GP. it would feature multidirectional The null point is important as it is nystagmus 3 and neurological symptoms. used during management, which is We referred the patient for ocular aimed at damping the nystagmus movement recordings and the results • Spasmus nutans: associated with movement and improving vision and confirmed a jerk nystagmus with a null gliomas of the anterior visual pathway cosmetic appearance. It is also crucial zone at 10–20 degrees right gaze. Given and ruled out by MRI. It presents to exclude abnormalities of the visual these findings and an exclusion of all with nystagmus that can be constant, pathway, systemic conditions or brain differentials, the patient was diagnosed intermittent or ‘shimmering,’ typically lesions as they can be life-threatening. with INS. with head nodding. Surgical intervention for INS can also be beneficial under certain conditions. Management consisted of the spectacle • CNS disorders: for example: multiple correction R -1.75/-0.25 x 170 L -2.00 sclerosis, adrenoleukodystrophy. (an over-correction of -1.00) with yoked Suspected with relative afferent CASE REPORT prisms incorporating 4 Base Left and pupillary defect, optic atrophy or 4 Base Out prism in each lens. The abnormal MRI testing. final distance visual acuity was 6/9, N5 A seven-year-old Caucasian male reading vision and the angle of left head • Latent nystagmus: can co-exist presented with a history of reduced turn was approximately halved, which with infantile nystagmus, detected by vision and nystagmus from the age was considered a good improvement. nystagmus increasing with monocular of two months. His parents were not While surgical intervention to correct cover and often occurs with a aware of any changes since its onset. the remaining head turn was considered, strabismus. The patient had seen an optometrist given his full binocular status the two years previously, wore glasses of possible benefit of this was outweighed. MANAGEMENT APPROACHES bilateral -0.75 obtained from that visit, and no other management options had Because contact lenses improve Ocular movement recordings been discussed. subjective visual quality in patients with INS,2 this was offered as a treatment The only laboratory currently offering No other ocular conditions were noted option. The parents decided to delay ocular movement recordings is located and the patient reported no oscillopsia. this option until he was more mature. Clinical observation showed horizontal Overall, the patient achieved an Continued page 24 24 MARCH 2018

cent and 40 per cent, respectively. It because he was achieving satisfactory INS is thought that contact lenses dampen vision and we did not want to interrupt nystagmus via trigeminal afferent his full binocularity. From page 23 feedback mechanisms. Weighing up the risk factors for contact lens wear, Prognosis in Melbourne. It is a valuable test to which include microbial infections quantitatively evaluate the pattern and physical ocular damage, versus Nystagmus waveforms and frequencies of eye movement and to classify the the subjective visual improvement, typically decrease until the age of nystagmus. A jerk movement of the contact lenses constitute a considered six-to-eight years and remain stable eye in nystagmus consists of a slow management option. afterwards.13 If changes do occur, and a fast phase. Assessment of the they need to be investigated because slow phase can actually help locate a diagnosis of INS does not preclude Surgery causative lesions of the ocular motor the possibility of developing other subsystem as well as objectively Surgery aims to shift and widen neurological or ocular issues. locating any null points.4 the null zone and reduce overall eye movement intensity, thereby Aetiology eliminating abnormal head posture and Spectacles and prisms improving vision. The Kestenbaum- INS is understood to be genetic, and Considering that the refractive error Anderson technique involves a studies have demonstrated a mutant for patients with INS ranges from paired recession and resection of the gene FRMD7 for X-linked idiopathic -7.88 to +4.00 with a mean of -1.37,5 antagonistic rectus muscles in each INS.14 However, it can appear without the basic correction of refractive error eye to move the null zone to primary a known family history. The aetiology shouldn’t be overlooked. Strabismus, if position. If convergence damping is not currently well understood. One present, should be corrected to improve is present, a combination of the theory by Brodsky15 suggests that INS binocularity.6 Patients with INS may Kestenbaum-Anderson with a paired occurs when foveal motion sensitivity indicate that their vision worsens surgical divergence of the horizontal is slow to mature in infancy. This causes under visual stress, and indeed it has rectus muscles gives the best results.9 a secondary delay in development of been shown that when faced with tasks The presence of a lateral null zone is the high-frequency cortical pursuit containing a higher mental load, visual required to obtain best results from pathways which are usually responsible recognition times increase for people these techniques. for suppressing the optokinetic motion with INS compared to a control group.7 perceived during eye movements and This further supports the emphasis Four-muscle recession is a surgical nystagmus subsequently develops. on correcting refractive errors and intervention aimed to weaken the reducing visual stress. muscular force of all four rectus A contrasting theory by Harris and muscles. A study demonstrated Berry16 proposes that nystagmus If the patient shows convergence, improved vision with this technique, develops in the retina lacking damping the use of base-out prism more so for participants under the age of maturation as a compromise to and -1.00 overcorrection creates a 10 years who improved an average 1.9 enhance contrast sensitivity on a retina convergence demand and in this way lines of distance visual acuity compared by use of motion while maintaining reduces nystagmus.6,8 In addition, if to participants over the age of 10 who some foveal fixation. Work by the patient exhibits a lateral null point, improved 1.4 lines.10 However, visual Dell’Osso et al17 created a computer which can be tested by observing acuity improvements must be larger model simulation which proposes eye movement intensity in different than the test-retest variable (two lines that pendular nystagmus in INS is due directions of gaze, yoked prisms can on the Snellen chart)9 to be considered to a loss of damping of the normal shift the visual image from lateral to clinically effective. Large limitations pursuit-system velocity oscillation. primary gaze and correct abnormal of ocular motility post-surgery were Furthermore, electron microscopy head postures. This can be done demonstrated, as well as cases of post- studies of extraocular muscle tissue in effectively without degrading image operative nerve palsy and exotropia.11 INS subjects found anomalous nerve quality only when the angle of null is endings and vascular endothelial minor. The amount of prism can be Lastly, extraocular muscle tenotomy cells.18 Whether this could contribute determined by trialling lenses while involves cutting and reattaching the to INS is still being researched. observing the nystagmus intensity and extraocular muscles at the same site repeating visual acuity, with patient of attachment. The exact mechanisms Conclusion feedback when possible. of action aren’t known but could involve disruption of motor neuron If a patient presents with nystagmus, proprioceptive signals. For this it is important to perform a thorough Contact lenses technique, published reports have history and clinical examination. INS is A study by Pavitra et al3 compares demonstrated improved nystagmus based on characteristics including age the visual results with spectacles, soft and visual function with no significant of onset and typical features; however, contact lenses (SCL) and rigid gas- adverse effects.12 However, these studies it is also a diagnosis of exclusion permeable contact lenses (RGP) in have a low number of participants and because the differentials can be life- INS. While there was no statistically- further studies are required. threatening. There is a number of significant difference, the numbers management approaches and this case of patients who reported visual For our young patient, the risks of study demonstrates the opportunity improvement with SCL and RGP post-surgical ocular motility limitations optometrists have to improve the quality compared to spectacles were 30 per and exotropia outweighed the benefits of vision for these patients. MARCH 2018 25

1. Wray S. Eye movement disorders in clinical practice. Oxford Publishing, 2014; pp 380. 2. Pavitra J. Randomized controlled Floaters trial comparing soft contact lens and rigid gas permeable lens wearing in infantile nystagmus. Ophthalmology A clinical and surgical update 2014; 121: 9: 1827–1836. 3. Cogan DG. Ocular dysmetria, flutter- like oscillations of the eye and presented options for the motivated, opsoclonus. Arch Ophthalmol 1954; 51: 318–335. Dr Simon Chen symptomatic patient. 4. Abel LA. Infantile nystagmus: current concepts in diagnosis and BSc(Hons) MBBS FRCOphth management. Clin Exp Optom 2006; Here we present a short review on 89: 57–65. FRANZCO the clinical assessment and surgical 5 Sampath V, Bedell H. Distribution management of floaters, highlighting of refractive errors in albinos and Vision Eye Institute, Sydney, NSW persons with idiopathic congenital recent advances in the care of this nystagmus. Optom Vis Sci 2002; 79: condition. 292–299 Dr Chris Hodge 6. Hertle RW. Examination and refractive management of patients PhD BAppSc What are floaters? with nystagmus. Surv Ophthalmol 2000; 45: 215–222. Vision Eye Institute, Melbourne, VIC Floaters originate from molecular 7. Fadardi S. The effects of task-induced stress and mental workload on visual changes occurring within the vitreous performance and eye movement body or at the vitreoretinal interface. behaviour in nystagmus and controls Although most cases are related to the [PhD.]. The University of Melbourne; 2018. ageing process, a variety of endogenous 8. Richards M, Wong A. Infantile Recent studies have confirmed and exogenous factors may contribute to nystagmus syndrome: clinical the development of floaters (Figure 1). characteristics, current theories anecdotal findings that floaters are of pathogenesis, diagnosis, and very common with between 76 The severity of symptoms and signs are management. Can J Ophthalmol 2015; per cent and 84 per cent of study often related to the type and location 50: 400–408. of the floaters, so an understanding of 9. Zubcov A, Stärk N, Weber A, et participants reporting floaters on al. Improvement of visual acuity questioning.1,2 Although most patients these may assist in the diagnosis and after surgery for nystagmus. with floaters are not very troubled by management of the patient’s condition. Ophthalmology 1993; 100: 1488-1497. 10. Lingua R, Liu C, Gerling A, et al. them, the same studies confirm that Myectomy of the extraocular muscles a minority of patients complain of Primary vitreous floaters arise from without reattachment as a surgical significant visual symptoms. structures within the vitreous body treatment for horizontal nystagmus. J 4 Pediatr Ophthalmol Strabismus 2016; itself. Collagen fibres within the 53: 156-166. In symptomatic patients, the impact vitreous continue to increase in 11. Helveston E, Ellis F, Plager D. on quality of life can be significant, number, thickness and irregularity Large recession of the horizontal recti for treatment of nystagmus. even in the absence of marked clinical throughout life. As these fibres move Ophthalmology 1991; 98: 1302-1305. findings. Historically, the management across the patient’s visual axis, the 12. Hertle R, Dell’Osso L, FitzGibbon E, of floaters has involved a ‘wait and light is scattered, or, if significant, they et al. Horizontal rectus tenotomy in patients with congenital nystagmus. see’ approach with a recommended cast a shadow onto the retina, leading Ophthalmology 2003; 110: 2097-2105. period of adjustment and resolution to the presence of dark lines across the 13. Atilla H. Assessment and visual field. Progressive liquefaction management of infantile nystagmus with time despite clinical findings syndrome. J Clin Exp Ophthalmol to suggest otherwise.3 More recently, 2016; 7: 550. vitrectomy and YAG vitreolysis have Continued page 26 14. Thomas MG, Thomas S, Kumar A, et al. FRMD7-related infantile nystagmus. In: Adam MP, Ardinger HH, Pagon RA, et al, editors. Gene Reviews [monograph on the Internet]. Seattle (WA): University of Washington, Seattle; 2009: 1993-2017. Available from: https://www.ncbi. nlm.nih.gov/books/NBK3822/. 15. Brodsky M, Dell’Osso L. A unifying neurologic mechanism for infantile nystagmus. JAMA Ophthalmology 2014; 132: 761. 16. Harris C, Berry D. A developmental model of infantile nystagmus. Semin Ophthalmol 2006; 21: 63-69. 17. Jacobs J, Dell’Osso L. Congenital nystagmus: Hypotheses for its genesis and complex waveforms within a behavioral ocular motor system model. Journal of Vision 2004; 4:7 18. Hertle R, Chan C, Galita D, et al. Neuroanatomy of the extraocular muscle tendon enthesis in macaque, normal human, and patients with congenital nystagmus. J Amer Assoc Pediatr Ophthalmol Strabismus 2002; 6: 319-327. Figure 1. Age-related degenerative floaters on fundus examination 26 MARCH 2018

Figure 2. Floaters as a result of fungal infection Figure 3. Inflammation leading to vitreous floaters

of inflammation, infection or as well as features associated with Floaters haemorrhage, or following intraocular systemic causes of uveitis such as surgery. The presence of secondary fever, cough, joint pain or rashes. From page 25 floaters is often accompanied by visual Systemic conditions associated with disturbances (Figure 2). uveitis include a wide variety of autoimmune, infectious and idiopathic and mobility of the vitreous with age conditions (Figure 3). Assessment increases light scatter by the collagen fibrils, and increases the potential A detailed patient history remains the Of importance generally, floaters may clinical impact for the patient. foundation for clinical assessment. represent the early clinical signs of a Acute onset and increasing numbers broader infectious process. A recent Posterior vitreous detachment: the end of floaters are indications for urgent review from the Royal Victorian Eye result of this process, in approximately assessment. Associated ocular and Ear Hospital identified floaters 60 per cent of patients, often leads to symptoms such as flashing lights, and blurred vision as the presenting a sudden increase in primary floaters.5 visual field defects or blurred vision sign in a series of patients who were Clear noodle- or worm-shaped floaters may indicate the presence of a retinal later diagnosed with ocular syphilis are separately described and reflect tear or retinal detachment. Patients despite an absence of redness and the presence of the existing hyaloid with uveitis may present with floaters ocular discomfort.6 A history of structure. Rarely do these floaters lead caused by inflammatory cells which intraocular surgery may be relevant. to patient discomfort. have gained access to the vitreous Intravitreal injections of triamcinolone cavity via a compromised blood-retina can result in residual white particles Secondary floaters originate from barrier. Patients should be asked about within the vitreous, which tend to changes exogenous to the vitreous possible features of uveitis such as gravitate inferiorly. Tiny lens particles body and may occur as a result photophobia, redness or discomfort, in the anterior vitreous are commonly

Figure 4. Lens fragments within the posterior Figure 5. Slitlamp assessment of vitreous Figure 6. Weiss Ring as seen on vitreous chamber following cataract surgery examination MARCH 2018 27

seen following phacoemulsification surgery in the early post-operative period (Figure 4).

Patients may also become more aware of pre-existing floaters and become symptomatic after cataract surgery when their vision has improved. Multifocal intraocular lenses are increasingly utilised for patients seeking optical independence following surgery. The multiple focal points inherent to these lens designs can make these patients particularly prone to symptoms from floaters as they may more easily see floaters at multiple planes within the vitreous cavity.

Slitlamp biomicroscopy allows for a thorough examination of the vitreous. Using a bright thin slit beam offset by 10 degrees from the visual axis enables the examiner to visualise the posterior hyaloid membrane behind the lens in patients with an advanced posterior vitreous detachment (Figures 5 and 6). A search for the presence or absence Figure 7. Peripheral retinal tear with vitreous haemorrhage of floaters, pigment (‘tobacco dust’), red blood cells or white cells behind the lens should be done. Asking the patient to look down and then straight their location (anterior/posterior or visualise floaters located within the ahead mobilises the vitreous and may diffuse/inferior), colour (white/brown, pre-macular bursa area. The pre- bring cells within the inferior vitreous red), shape (ring/strands, snowball or macular bursa is an optically empty into view. clumps), size and mobility as these vitreous cistern located immediately features provide information regarding anterior to the macular. Floaters All patients presenting with floaters the possible aetiology of the floaters, in young patients are often located should be assumed to have a retinal their visual impact and the potential within the pre-macular bursa and tear present until proven otherwise by treatment options. Imaging of the can be extremely difficult to see on careful assessment of the peripheral floaters, using a retinal camera or a slitlamp examination. Due to their retina. Approximately 10 per cent scanning laser ophthalmoscope (often proximity to the retina, floaters in the of retinal tears cannot be seen with incorporated in many OCTs) may pre-macular bursa are typically well commonly-used 90 D lenses as they be useful for patient education and defined and can cause a high level are located anteriorly near the ora documentation. of symptoms. It is not uncommon serrata, mandating the need for scleral for patients with floaters in the indentation (Figure 7). When no floaters are visible to the pre-macular bursa to have visited examiner in a patient complaining When examining floaters, consider of floaters, OCT may be helpful to Continued page 28

Figure 8. Ocular coherence tomography of pre-macular bursa (left), fundus imaging of pre-macular bursa floater (middle), OCT of same eye indicating pre-macular bursa (right) 28 MARCH 2018

Floaters From page 27 numerous eye-care practitioners who have been unable to identify the troublesome floaters.7 OCT may show the floaters located anterior to the macular (Figure 8).

Treatment If significant, floaters may warrant surgical intervention. The decision to proceed with treatment is determined by numerous factors including the impact of the floaters on the patient’s quality of life, patient expectations, age, location and contributing cause of the floaters.

YAG laser vitreolysis is a relatively recent innovation in which a YAG laser is used to vaporise floaters and prevent them from obstructing Figure 9. Bubble post vitrectomy the visual axis. The procedure is performed in the clinic using slitlamp visualisation, averting the need to lens, highlighting a potential risk of 1. Webb BF, Webb JR, Schroeder MC, et visit an operating theatre. Multiple the procedure.9–10 al. Prevalence of vitreous floaters in a community sample of smartphone treatment sessions may be needed and users. Int J Ophthalmol 2013; 6: complete symptom resolution is often Vitrectomy surgery to remove floaters 402–405. 2. Tassignon MJ, Ní Dhubhghaill S, Ruiz not possible. YAG laser vitreolysis is an option if symptoms significantly Hidalgo I, Rozema JJ. Subjective grading works best for patients with a small affect the patient’s quality of life and of subclinical vitreous floaters.Asia Pac number of large, easily-visible floaters the patient has been unresponsive to J Ophthalmol (Phila) 2016; 5: 104–109. 3. Wagle AM, Lim WY, Yap TP, et al. located in the mid-vitreous cavity not or unsuitable for YAG laser vitreolysis. Utility values associated with vitreous too close to the lens or the retina. The Vitrectomy surgery typically allows floaters. Am J Ophthalmol 2011; 152: ideal patient is middle-aged with a removal of all symptomatic floaters 60–65.e1. 4. Milston R, Madigan MC, Sebag J. large symptomatic Weiss ring. and results in high levels of patient Vitreous floaters: Etiology, diagnostics, satisfaction. The main disadvantage and management. Surv Ophthalmol YAG laser vitreolysis is not suitable of vitrectomy surgery is the premature 2016; 61: 211–227. 5. Yonemoto J, Ideta H, Sasaki K, et al. for patients with floaters that cannot development of cataract. In patients The age of onset of posterior vitreous be easily visualised on slitlamp aged older than 50 years at the time of detachment. Graefes Arch Clin Exp examination, those with large numbers surgery, cataract formation typically Ophthalmol 1994; 232: 67–70. 6. Ong D, Bhardwaj G, Ong J, et al. of floaters or those with floaters develops within one year and requires Keeping an eye on syphilis. Aust Fam located close to the lens or retina, cataract surgery. The most serious Physician 2017; 46: 401–404. due to the potential for the laser to risks of vitrectomy surgery include 7. Tseng GL, Chen CY. Doctor-shopping behavior among patients with eye inadvertently hit these structures. endophthalmitis (approximately one floaters. Int J Environ Res Public Health A large proportion of patients aged in 1,000) and retinal detachment (up 2015; 12: 7949–7958. younger than 35 years are unsuitable to one per cent)11 (Figure 9). 8. Shah CP, Heier JS. YAG Laser vitreolysis vs sham YAG vitreolysis because they frequently have floaters for symptomatic vitreous floaters: located in the pre-macular bursa a randomized clinical trial. JAMA Summary Ophthalmol 2017; 135: 918–923. which are too close to the macula for 9. Hahn P, Schneider EW, Tabandeh H, et safe application of laser. Floaters are very common and al. Reported complications following their impact on quality of vision is laser vitreolysis. JAMA Ophthalmol 2017; 135: 973–976. Published case series describing the highly variable. Accurate diagnosis 10. Sun IT, Lee TH, Chen CH. Rapid efficacy of YAG laser vitreolysis have and careful clinical assessment are cataract progression after Nd:YAG reported generally positive results. essential to exclude sight-threatening vitreolysis for vitreous floaters: a case report and literature review. Case Rep A recent randomised control trial conditions such as retinal detachment Ophthalmol 2017; 8: 321-325. comparing laser vitreolysis against or uveitis. Motivated patients may 11. Sebag J, Yee KM, Wa CA, et al. sham treatment demonstrated both benefit from surgical intervention Vitrectomy for floaters: prospective efficacy analyses and retrospective subjective and objective improvements which has largely been shown to be safety profile.Retina 2014; 34: 1062– for patients treated with laser.8 safe and effective. Consideration of 1068. There have been case reports of age, the causative factor of the floaters secondary cataract caused by the laser and patient expectations are essential inadvertently hitting the crystalline prior to considering surgical options. Race to reduce IOP*

*Mean IOP reduction of up to 8.7 mmHg from baseline maintained over 24 hours with once daily dosing, over 3 months1

Travatan BAK-free contains POLYQUAD preservative2 POLYQUAD has minimal toxicity to mammalian cells.3 For patients with glaucoma, consider BAK-free medicines as an alternative treatment option when available.

IOP: Intraocular pressure; mmHg: Millimetres of mercury

PBS Information: This product is listed on the PBS for elevated intra-ocular pressure. Please review full Product Information before prescribing. For the most up to date Product Information go to http://www.novartis.com.au/products_healthcare.html TRAVATAN (travoprost 0.004%) Eye Drops. Indication(s): As first line monotherapy or adjunctive therapy to decrease elevated intraocular pressure in patients with ocular hypertension and/or open angle glaucoma. Dosage and administration: One drop in the conjunctival sac of the affected eye(s) each day. Shake the bottle well before use. Contraindications: Hypersensitivity to travoprost or any of the excipients in the medicine; pregnant women or women attempting to become pregnant. Precautions: Use with caution in aphakic patients, pseudophakic patients with torn posterior lens capsule or anterior chamber lenses, patients with known risk factors for macular oedema. No experience in in inflammatory ocular conditions, inflammatory, neovascular, angle closure or congenital glaucoma and only limited experience in open angle glaucoma of pseudophakic patients and in pigmentary glaucoma. Therefore, use with caution in patients with active intraocular inflammation and/or predisposing risk factors for iritis/uveitis. Patients should be informed about possible changes to eye colour, eyelash thickness and/or length and periorbital and/or eyelid skin darkening. Patients who continue to wear soft contact lenses must be instructed to remove contact lenses prior to administration and wait 15 minutes after instillation of the dose before reinsertion. Use in paediatric patients has not been established. Use in pregnancy: Category B3. Use in lactation: there is no data on excretion into human milk, patients should stop breastfeeding. May cause transient blurred vision following instillation, which may impair the ability to drive or operate machinery. Interactions with Other Medicines: Drug-drug interactions involving protein binding are unlikely; Concomitant therapy with miotics or adrenergic agonists has not been evaluated. Adverse Effects: Very common (≥10%): conjunctival hyperaemia, ocular hyperaemia, iris hyperpigmentation. Common (1 to <10%): punctate keratitis, anterior chamber cell, anterior chamber flare, eye pain, photophobia, eye discharge, ocular discomfort, eye irritation, abnormal sensation in eye, foreign body sensation in eyes, visual acuity reduced, vision blurred, dry eye, eye pruritus, lacrimation increased, erythaema of eyelid, eyelid oedema, eyelids pruritis, growth of eyelashes, eyelash discolouration, headache, skin hyperpigmentation (periocular), skin discolouration. Less frequent adverse effects are listed in the full Product Information. (tra040717m based on tra040717i). For medical enquiries please contact 1800 671 203 (phone) or medinfo.phauno@novartis. com (email) REFERENCES: 1. Gandolfi S et al. Eur J Ophthalmol 2012; 22(1): 33–44. 2. Travatan (travoprost 0.004%) Eye Drops Product Information. 4 July 2017. 3. Rolando M et al. Expert Opinion on Drug Deliv 2011; 8(11):1425–1438. ®Registered trade mark. Novartis Pharmaceuticals Australia, 54 Waterloo Road, Macquarie Park, NSW 2113. AU-4682 Date of preparation: February 2018. NOGL13153W.

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PBS Information: Authority Required (STREAMLINED): Severe dry eye syndrome in patients who are sensitive to preservatives in multi-dose eye drops.

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