ISSN 0972-0200 Original Article

Diseases Causing Defects at Shimla Hills

Delhi J Ophthalmol 2014; 25 (2): 95-98 DOI: http://dx.doi.org/10.7869/djo.86

Kalpana Sharma, Kulbhushan Introduction: : Visual field (VF) measurement is the critical component for elucidating pathological Prakash Chaudhary, conditions affecting not only ophthalmological but also neurological system. Ravinder Kumar Gupta, Objective: To study the types and disease pattern distribution, among the patients who underwent Ram Lal Sharma automated perimetry. Dept. of Materials and Methods: This study was the analysis of visual fields, (August 2008 to July 2010), of Indira Gandhi Medical College, the patients who underwent visual field recording on Octopus 900 perimeter (HAAG- STREITAG, Shimla, India Switzerland) at Shimla hills (IGMC H.P.) situated at the height of 7,200 feet above sea level. Results: The causes of visual field defects(VFD) were 59.5% (n=119); Neurological causes *Address for correspondence 16.5% (n=33); 7.5%(n=15); ARMD 4.5% (n=9); BRVO 4%(n=8); DR 3%(n=6); AION 2%(n=4); RP 1.5%(n=3) ; 1.5% (n=3).The severity of glaucoma(advance glaucomatous VFD) increased with age significantly (p value=0.03345). Conclusion: The most common disease leading to VFD was glaucoma. The severity of glaucomatous damage increased with age significantly (p<0.05).The mean sensitivity decreases numerically with age. The next common cause leading to VFD was neurological in which the most common VFD was quadrantanopia. The other causes of VFD were cataract, ARMD, BRVO, CRVO, DR, AION, RP and Kalpana Sharma MS optic neuritis. . This pattern of VFD was seen because Glaucoma screening is one of the commonest Bhardwaz cottage, indications to carry out visual field analysis followed by neurological indications in our set up. Near Govt. Dispensary Keywords : visual field • automated perimetry • octopus 900 perimeter Lower Jakhoo Shimla 171001 Email: [email protected] Visual field measurement is a critical used to develop more glaucoma- specific component in the armament against grids, such as the “G-1”program from the potentially blinding diseases. Perimetry Octopus perimertes.2,3 is used extensively in diagnosis and follows up of several eye diseases Materials and Methods such as in glaucoma, diseases of In this study the visual fields of and neurological diseases.1 The use in the patients were recorded on Octopus glaucoma is often discussed and well 900 perimeter (HAAG-STREIT AG understood, however it has various other Switzerland) in our institution. It included applications that render it very useful all the reliable (Reliability factor <15) in disease management and blindness visual fields. Unreliable visual fields were prevention. These include the detection excluded from the study which comprised: and/or management of conditions such as False positive catch trials more than 15%, intraorbital lesions, , false negative catch trials more than 15%., pigmentosa, cranial tumours and others. Reliability factor value more than 15. Visual field measurement has undergone an evolution from the mechanical to The standard Octopus examination the automated measurement process, parameters included: Background resulting in greater accuracy, ease of luminance of 1.27 cd/m2 (4asb), background use and greater depth of analysis. The colour white, stimulus size of 0.430 early generation automated perimetres diameter, stimulus colour of white and generally used symmetric test grids exposure of 100 ms. The visual fields were that purposely did not emphasize any analysed according to following criteria: particular area of visual field. Data Morales et al4 stated Octopus criteria for from these early symmetric programs, visual field defects as MD(mean deviation) combined with data from manual greater than 2dB,LV (loss of variance) perimetric examinations , have been greater than 6dB and at least 7 points with

95 Del J Ophthalmol 2014;25(2) E-ISSN 0976-2892 An Analysis of Automated Perimetry Original Article

sensitivity decreased >5dB, three of them being contiguous. right eye and left eye shows (Table 3). In (Table 3) Mean Visual field severity grading was done according to sensitivity decreases numerically with age in right eye. In classification proposed by Mills et al.5 pairwise comparison the mean difference of 3.366 at value According to Thomas R et al6 field defects in neurological 0.043 was significant between age groups 50-59 and >70 yrs. lesions, patients were classified into: Quadrantanopia, (mean difference being significant at level 0.05). The age- Hemianopia; Quadrantanopia was diagnosed if either of the wise comparison in other groups was insignificant. Mean following criteria were fulfilled1. Depression of thresholds sensitivity decreases numerically with age in left eye. The by 5 dB or more, in 3 or more contiguous points adjacent to Mean difference between age <40 yrs. and age groups 60-69 the vertical meridian in the involved quadrant as compared was 7.004 at level 0.020 (mean difference sig at 0.05 level). to their mirror image points across the vertical meridian.2 The mean difference of mean sensitivity between age <40 The corrected probability plot showed 3 or more points yrs. and >70 yrs. was 6.654 at the level 0.017 (mean difference adjacent to the vertical meridian in the involved quadrant significant at the 0.05 level). The mean difference between depressed to the 1 % probability level with normal mirror other age groups being insignificant (p >0.05) Neurological image points across the vertical meridian. For the diagnosis lesions lead to VFD in 33 patients. The distribution of VFD of hemianopia, the diagnostic criteria for quadrantanopia were as follows (Table 4). In neurological lesions bitemporal had to be applicable to both quadrants comprising the hemianopia was seen in six patients having pituitary hemifield. adenomas. Two patients had binasal hemianopias with Statistics: Data collected was managed on a Microsoft ICA aneurysms and 3rd ventricular enlargement on CT office excel spreadsheet. Discrete variables were expressed respectively. Six patients had right upper quadrantanopia in percent and continuous variables were expressed as and 6 patients had left upper quadrantanopia with lesions Mean +/- Standard deviation. Chi-square test was used to assess the significance of any difference between the two Table 1: Distribution of various causes of VFD groups in discrete variables. Diseases Frequency Percentage (%) Glaucoma 119 59.5 Results Neurological causes 33 16.5 A total of 500 visual fields were analysed out of which normal fields were 60. The unreliable VF were 40 which were Cataract 15 7.5 excluded from the study as per exclusion criteria. Age of the ARMD 9 4.5 patients ranged from 9 –92 yrs. with mean age of 60.4350 ± BRVO,CRVO 8 4 14.797. The study comprised 128 males and 72 females. Out of various causes of VFD (n=200), glaucoma caused VFD in DR 6 3 119 (59.5%) patients, while neurological causes lead to VFD AION 4 2 in 33 (16.5%). Cataract caused VF artefacts in 15 patients. RP 3 1.5 The other causes of VFD include ARMD, AION, RP, optic Optic neuritis 3 1.5 neuritis, DR and BRVO (Table 1). Depending upon MD score, distribution of VF severity in glaucoma showed distribution Total 200 100 as per (Table 2). This distribution (Table 2) thereby showed that in <50 years earliest and early glaucomatous VFD were Table 2: : Distribution of severity of glaucoma seen in 6 eyes; 22 patients >50 years had earliest and early Severity of glaucoma <40 40-49 50-59 60-69 >70 VFL. 16 eyes <50 years had moderate (n=0), advanced (n=6), severe (n=9) and end stage (n=1) glaucoma VFL whereas 179 Earliest VFD 2 0 0 0 1 eyes >50 years had moderate (n=50), advance (n=53), severe Early VFD 0 4 9 7 5 (n=50) and end stage (n=26) glaucoma VFL. On chi square Moderate VFD 0 0 18 13 19 test p value =0.03345 (p value sig. at 0.05) showing that Advance VFD 0 6 14 9 30 severity of glaucoma increased with age. On applying estimated marginal means age wise Severe VFD 0 6 10 18 22 distribution of mean sensitivity in glaucoma patients for End stage VFD 1 0 3 9 14

Table 3: Distribution of mean sensitivity in right and left eye Age group Right eye Mean sensitivity Left eye Mean sensitivity Lower – Upper limits Lower –Upper limits 95% CI (Lt eye) 95% CI (Lt eye) <40 17.700 21.000 8.633 - 26.767 16.034 - 25.966 40-49 15.844 16.400 11.570 - 20.119 7.799 - 25.001 50-59 16.279 15.405 13.662 - 18.897 12.228 - 18.581 60-69 13.996 13.996 11.322 - 16.669 10.889 - 17.102 >70 12.914 12.346 10.981 - 14.847 10.149 - 14.542

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for VFL was degenerative followed by glaucoma Table 4: VFD in neurological lesions and disease and cataract. In subjects aged 60- Type of VFD Frequency 69 the most frequent cause of VFL was cataract followed by glaucoma and degenerative myopia. In subjects aged 70 or Bilateral temporal heminopias 6 above the most frequent causes were glaucoma, cataract, Bilateral nasal heminopias 2 and degenerative myopia. In comparison to Rotterdam Right lower quadrantanopia 9 study, ARMD and retinal vessels diseases that included diabetic and retinal vascular occlusion were Left lower quadrantanopia 1 not major causes of VFL in Beijing study. The reasons for Right upper quadrantanopia 6 this discrepancy in the ranking of the various causes of Left upper quadrantanopia 6 VFL between the Rotterdam study and the Beijing study is unclear but differences in the lifestyles, eating habits and Right homonymous heminopia with 3 other parameters may have an influence. In our study people macula sparing who were <40 yrs. the most common cause of VFL was neurological (n=5) followed by cataract (n=4) and glaucoma in temporal lobe tumorous growth (n=2), head trauma (n=3), (n=3); in subjects aged 40-49 yrs. most common cause of CVA infarct (n=3), neurocysticercosis (n=1), arachnoid cyst VFL was Glaucoma (n=9) followed by neurological cause (n=1), abscess (n=2).Right homonymous hemianopia with (n=5). In patients aged 50-59 yrs the most common cause of macular sparing found in 3 patients with old infarct (n=2) VFL was Glaucoma (n=31) followed by neurological cause and head trauma (n=1). (Table 5) shows Distribution of VFD (n=13) and AION (n=4); In patients aged 60-69 yrs. the most in other diseases. common cause of VFL was Glaucoma (n=28) followed by ARMD (n=6) and cataract (n=5); In subjects aged >70 yrs. the Table 5: Distribution of VFD in other diseases most common cause of VFL was Glaucoma (n=48) followed ARMD AION Optic Cataract Retinitis Age group neuritis Pigmetosa by neurological cause (n=7) and cataract (n=4). <40 0 0 0 4 1 Mean sensitivity distribution showed that Mean sensitivity decrease numerically with age which was 40 - 49 0 0 0 1 1 statistical significance. Haas et10 al reported that the 50 - 59 0 4 1 1 0 differential light sensitivity begin to decline in youth and 60 - 69 6 0 1 5 1 continues to gradually decrease throughout life at rate of >70 3 0 1 4 0 0.58 dB/ decade. Zingirion M et al11 stated that perimetry analyses the efficacy of the entire but reveals Discussion the deterioration of even one of its components optic nerve Visual field testing is performed for several different changes especially those of ischaemic nature, which most purposes such as to detect the presence of suspected frequently involve middle and advanced age. In normal abnormality (glaucomatous defects or hemianopias), subjects every type of perimetry shows physiological decay to diagnose the cause of a visual loss and to quantitate of light sensitivity as a consequence of the ageing of the visual the degree of visual loss as a baseline to detect future system (about 2dB per decade) and reduced efficacy of optic progression. For these several tasks there may be different nerve is undoubtedly one of the functional deterioration. In strategies. With automated perimetres, users may select the this study Glaucoma was the commonest cause of VFD in appropriate stimulus duration and interval according to age groups >40 years followed by neurological field defects what seems best in the patients.7 in age group above 40 years, 50 - 59 years and >70yrs. The In the Rotterdam study Raan S. Ramrattan etal8 other causes of VFD were ARMD, BRVO, CRVO, DR, AION, determined the prevalence and causes of visual field loss RP and optic neuritis. This pattern of VFD was seen because (VFL) and the association between VFL and indicators Glaucoma screening is one of the commonest indication of impairment in daily functioning among community- to carry out visual field analysis followed by neurological dwelling elderly patients 55 years and older using Goldman indications in eye OPD set up. perimeter. The overall prevalence of VFL was 5.6% (3.0% in those aged 55-64 to 17.0% in those ≥ 85 years); glaucoma was the leading cause of VFL in all age groups before the age of Conclusion 75; other optic nerve diseases and stroke ranked 2nd and The stimulus for this work was not only ophthalmological 3rd respectively as did age related macular degenerations but also neurological, for the exploration of VF is the most and retinal vein occlusive disease respectively after this age. important means at our disposal for elucidating pathological Yaxing Wang et al9 determined the prevalence and conditions affecting CNS in the region of visual pathway. The causes of VFL by frequency doubling perimetry in urban most common disease leading to VFD was glaucoma in our and rural China, which was population based cohort study. study. The severity of glaucomatous damage increased with It included 4439 subjects with an age above 40 years. The age significantly (p<0.05).The mean sensitivity decreases prevalence of VFL per eye increased from 5.3% in subject numerically with age. The next common cause leading to aged 40-49 to 25.9% in subject aged 70 years or older. In VFD was neurological in which the most common VFD was this study the subjects aged 40-49 the most frequent cause quadrantanopia. The other causes of VFD were cataract,

97 Del J Ophthalmol 2014;25(2) E-ISSN 0976-2892 An Analysis of Automated Perimetry Original Article

ARMD, BRVO, CRVO, DR, AION, RP and optic neuritis. automated perimetry. Invest Ophthalmol Vis.Sci 1985; 26:1 This pattern of VFD was seen because glaucoma screening 6 is one of the commonest indication to carry out visual field 4. Morales J, Weitzman ML, Gonzalez de la Rosa M. Comparison between Tendency Oriented Perimetry and Octopus threshold analysis followed by neurological indications in our set up. perimetry. Ophthalmol 2000; 107:134-142. However future long-term analysis of VF of patients, who 5. Mills RP , Bundez DL, Lee PP, Noecker RJ, Walt JG, Siegartel underwent automated perimetry, for a period of 5-10 years, LR, Evans SJ, Doyle JJ. Categorizing the stage of glaucoma will be helpful in strengthening and confirming the disease from pre-diagnosis to end stage disease. Am J Ophthalmol 2006; pattern of ocular and systemic diseases. 141:24-30. 6. Thomas R, Shenoy K, Seshadri MS, Muliyil J, Rao A, Paul P. Visual field defects in non-functioning pituitary adenomas. Financial & competing interest disclosure Indian J Ophthalmol 2002; 50:127-30. The authors do not have any competing interests in any product/ 7. Douglas R. Anderson, Programmed visual field testing. Tr. procedure mentioned in this study. The authors do not have any financial Am. Ophthal. Soc. Vol. LXXX , 1982: 326. 8. Raan S. Ramarattan, Roger C, Wolff W, Jost PJ, Bakker D, interests in any product / procedure mentioned in this study. Hofman A, Jong M. Prevalence and causes of visual field loss in the elderly and associations with impairment in daily References functioning (The Rotterdam study). Arch Opthalmol 2001; 119: 1788-94. 9. Wang W, Liang Xu, Jost b jones. Prevalence and causes of 1. Lynn JR, Fellman RI, Starita JR. Principles of perimetry. The visual field loss as determined by the frequency doubling Glaucoma 2nd ed St Louis: Mosby 1996: 491. perimetery in urban and rural adult Chinese. Am J Ophthalmol 2. Flammer J, Drance SM, Jenni A, Bebie H. JO and STATJO 2006; 141:1078-86. programs for investigating the visual field with the Octopus 10. Haas A, Flammer J, Schneider U. Influence of age on visual perimeter. Am J Ophthalmol 1983; 18:115. field on normal subject. Am J Ophthalmol 1986; 101:199-203. 3. Flammer J, Drance SM, Augustiny L, Funkhauser A. 11. Zingirian M. Perimetric aspects of optic nerve ageing. Metab. Quantification of glaucomatous visual field defects with Pediatr Syst. Ophthalmol 1989; 12:32-33.

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