Pattern Of Visual Field Defects Research Articles

HOMONYMOUS HEMIANOPIA IN CEREBRAL INFARCTION: CASE REPORT

Abstract
 Introduction : Homonymous hemianopsia is a visual field defect characterized by loss of half of the visual field in each eye. Cerebral infarction in the occipital lobe is the most common cause of homonymous hemianopsia. Sudden visual field loss should be considered as a cerebral infarction for prompt management.
 Case Illustration : Male 43 years old, vision in both eyes appears dark on the left side since 3 months ago, complaints occur suddenly. Patients with a history of hypertension (+) hypercholesterolemia (+). Ophthalmological examination revealed visual acuity in both eyes 6/6 with normal pupillary reflexesand normal fundoscopy in both eyes. Humphrey's visual field perimetry test showed left homonymous hemianopsia. A brain CT scan examination showed multiple cerebral infarctions in the right occipital lobe, cerebellum and basal ganglia bilaterally. The patient was referred to the neurology department for further treatment.
 Discussion : The visual field defect pattern is used to predict the location of the lesion in the visual pathway. Neurologic symptoms that may be present in occipital lobe lesions are migraine with aura and visual hallucinations. The patient had left homonymous hemianopsia where the results of brain CT scan showed multiple cerebral infarctions in the right occipital lobe.
 Conclusion : Manifestations of homonymous hemianopsia can predict the presence of cerebral infarction so that in the presence of visual field defects it can be used as a predictor of intracranial abnormalities for further evaluation and collaboration with the neurology department.

The TsiogkaSpaeth grid for detection of neurological visual field defects: a validation study

BackgroundThe TsiogkaSpaeth (TS) grid is a new, low-cost, and easy to access portable test for visual field (VF) screening which could be used by clinicians in everyday clinical practice. Our study aimed to determine the validity of an innovative screening grid test for identifying neurological disease-associated VF defects.MethodsWe enrolled two groups of participants: We assessed the one eye of ten consecutive adult patients with different types of neurological disease associated VF defects and ten eyes of controls in each group. The TS grid test was performed in each group. Sensitivity, specificity, and positive and negative predictive values of the TS grid scotoma area were assessed using the 24–2 VF Humphrey field analyzer (HFA) as the reference standard.ResultsSensitivity and specificity of the TS grid test were 100% and 90.91%, respectively. The area under curve was 0.9545 with 95% CI 0.87–1.00. There was a significant correlation between the number of missed locations on the TS grid test and the visual field index of the HFA 24–2 (r = 0.9436, P < .0001).ConclusionThe sensitivity and specificity of the TS grid test were high in detecting VF defects in neurological disease. The TS grid test appears to be a reliable, low-cost, and easily accessed alternative to traditional VF tests in diagnosing typical neurological patterns of visual field defects. It would be useful in screening subjects for neurologically derived ocular morbidity in everyday clinical practice and in remote areas deprived of specialized health care services.

Known genes, new genes and new phenotypes in mitochondrial eye diseases

Primary mitochondrial diseases together represent a major cause of inherited neurological disorders that, due to dysfunction of the mitochondrial respiratory chain, can affect many parts of body, especially high energy demand organs, such as liver, heart, kidney, muscle and the eye. As the eye is particularly vulnerable to mitochondrial dysfunction, approximately half of all the patients with confirmed mitochondrial disease will develop significant ocular involvement and the complication that patients are most afraid of is visual loss. This can arise either from a primary optic neuropathy (the most common ocular involvement), from outer retinal degeneration, or in some cases from retrochiasmal visual pathway involvement resulting in varying patterns of visual field defects. To date, inherited optic neuropathies have been linked with pathogenic variants in over 40 genes across both the mitochondrial (mtDNA) and nuclear (nDNA) genomes with maternal (mtDNA) inheritance, autosomal dominant, recessive and x‐linked inheritance observed. Inherited optic neuropathies are a significant cause of blindness in both the paediatric and adult population with an estimated prevalence of 1 in 10 000 in the UK. The prevalence is estimated low because of the difficulty in making a confirmed molecular diagnosis due to multiple factors: mutations have been identified in both genomes, a limited number of genes are included in next generation sequencing (NGS) panels, phenocopies etc. Current genetic testing strategies for inherited eye diseases fail to identify pathogenic variants in a significant proportion of cases suggesting that previously unidentified genes harbouring pathogenic variants remain to be identified. However, whole exome sequencing (WES) and particularly whole genome sequencing (WGS), and unbiased interrogation of genomic variants offers an unparalleled opportunity to detect variants in both uncharacterised genes and non‐coding regions of the genome leading to previously unknown gene‐disease associations. This presentation highlights the power of unbiased WGS to elucidate the missing heritability in mitochondrial eye diseases and reports novel gene‐disease associations and novel phenotypes associated with known genes defects.

Immunomodulatory and Antioxidant Drugs in Glaucoma Treatment.

Glaucoma, a group of diseases characterized by progressive retinal ganglion cell loss, cupping of the optic disc, and a typical pattern of visual field defects, is a leading cause of severe visual impairment and blindness worldwide. Elevated intraocular pressure (IOP) is the leading risk factor for glaucoma development. However, glaucoma can also develop at normal pressure levels. An increased susceptibility of retinal ganglion cells to IOP, systemic vascular dysregulation, endothelial dysfunction, and autoimmune imbalances have been suggested as playing a role in the pathophysiology of normal-tension glaucoma. Since inflammation and oxidative stress play a role in all forms of glaucoma, the goal of this review article is to present an overview of the inflammatory and pro-oxidant mechanisms in the pathophysiology of glaucoma and to discuss immunomodulatory and antioxidant treatment approaches.

The Patterns of Visual Field Defects in Primary Angle-Closure Glaucoma Compared to High-Tension Glaucoma and Normal-Tension Glaucoma

Introduction: The aim of this study was to compare the patterns of visual field (VF) defects in primary angle-closure glaucoma (PACG) to control groups of eyes with high-tension glaucoma (HTG) and normal-tension glaucoma (NTG). Methods: Forty-eight eyes with PACG were enrolled, and control eyes with HTG and NTG matched for age, sex, and mean deviation of VF defect were selected. VF tests were performed using the 24-2 program of the Humphrey field analyzer. VF defects were classified into six patterns with the Ocular Hypertension Treatment Study classification system and were categorized into three stages (early, moderate, and advanced). Each hemifield was divided into five regions according to the Glaucoma Hemifield Test (GHT). The mean total deviation (TD) of each GHT region was calculated. Results: Compared with HTG and NTG groups, the partial arcuate VF defects were more common in the PACG group. In the PACG group, the nasal GHT region in the inferior hemifield had the worst mean TD (−8.48 ± 8.62 dB), followed by the arcuate 1 (−7.81 ± 7.91 dB), arcuate 2 (−7.46 ± 7.43 dB), paracentral (−7.19 ± 7.98 dB), and central (−5.14 ± 6.24 dB) regions; the mean TD of the central region was significantly better than those for all other regions (all p Conclusion: Patterns of VF defect in PACG patients differ from those with HTG and NTG. This discrepancy might be due to the differences in the pathogenic mechanisms of glaucomatous optic neuropathy.

New genes and new phenotypes

AbstractPrimary mitochondrial diseases together represent a major cause of inherited neurological disorders that, due to dysfunction of the mitochondrial respiratory chain, can affect many parts of body, especially high energy demand organs, such as liver, heart, kidney, muscle and the eye. As the eye is particularly vulnerable to mitochondrial dysfunction, approximately half of all the patients with confirmed mitochondrial disease will develop significant ocular involvement and the complication that patients are most afraid of is visual loss. This can arise either from a primary optic neuropathy (the most common ocular involvement), from outer retinal degeneration, or in some cases from retrochiasmal visual pathway involvement resulting in varying patterns of visual field defects. To date, inherited optic neuropathies have been linked with pathogenic variants in over 40 genes across both the mitochondrial (mtDNA) and nuclear (nDNA) genomes with maternal (mtDNA) inheritance, autosomal dominant, recessive and x‐linked inheritance observed. Inherited optic neuropathies are a significant cause of blindness in both the paediatric and adult population with an estimated prevalence of 1 in 10 000 in the UK. The prevalence is estimated low because of the difficulty in making a confirmed molecular diagnosis due to multiple factors: mutations have been identified in both genomes, a limited number of genes are included in next generation sequencing (NGS) panels, phenocopies etc. Current genetic testing strategies for inherited eye diseases fail to identify pathogenic variants in a significant proportion of cases suggesting that previously unidentified genes harbouring pathogenic variants remain to be identified. However, whole exome sequencing (WES) and particularly whole genome sequencing (WGS), and unbiased interrogation of genomic variants offers an unparalleled opportunity to detect variants in both uncharacterised genes and non‐coding regions of the genome leading to previously unknown gene‐disease associations. This presentation highlights the power of unbiased WGS to elucidate the missing heritability in mitochondrial eye diseases and reports novel gene‐disease or gene‐phenotype associations.

Visual Field Defect Patterns Associated With Lesions of the Retrochiasmal Visual Pathway.

Perimetry is widely used in the localization of retrochiasmal visual pathway lesions. Although macular sparing, homonymous paracentral scotomas, and quadrantanopias are regarded as features of posterior retrochiasmal visual pathway lesions, incongruous hemianopia is regarded as a hallmark of anterior lesions. Recent studies have questioned the specificity of these defect patterns. Retrospective record review conducted in a single, academic, medical center using an electronic search engine with the terms ""homonymous hemianopia," "optic tract," "temporal lobectomy," "visual field defect," and "MRI." Patients were included if they had reliable, automated, static visual fields, high-quality reviewable MRI scans, and pertinent lesions. MRI lesions were assigned to 1 of 6 retrochiasmal visual pathway segments by the study neuroradiologist. Two study authors independently reviewed the visual fields and designated 10 different defect patterns. From an original cohort of 256 cases, only 83 had MRI-defined lesions that were limited to particular retrochiasmal segments and had visual field defect patterns that allegedly permitted localization to those particular segments. The 5 contralateral nerve fiber bundle defects were exclusive to optic tract tumors with rostral extension. Pie-in-the-sky defects were exclusive to Meyer loop lesions. Among 22 fields with macular sparing, 86% arose from the visual cortex or posterior optic radiations. Among 31 fields with homonymous quadrantanopias, 77% arose from Meyer loop, visual cortex, or posterior optic radiations. Among 13 fields with homonymous paracentral scotomas, 69% arose from visual cortex or posterior optic radiations. Optic tract lesions accounted for 70% of incongruous hemianopias but that pattern occurred uncommonly. In correlating discrete MRI-defined retrochiasmal lesions with visual field defect patterns identified on static perimetry, this study showed that macular sparing, homonymous paracentral scotomas, and quadrantanopias localized to the visual cortex and posterior optic radiations segments but not exclusively. It has differed from an earlier study in showing that incongruous hemianopias occur predominantly from optic tract lesions.

Junctional Scotoma and Patterns of Visual Field Defects Produced by Lesions Involving the Optic Chiasm.

Lesions of the optic chiasm (OC) typically produce bitemporal hemianopia (BTH) on visual field (VF) testing, whereas lesions located at the nasal optic nerve-chiasmal (ON-OC) junction have been proposed to produce junctional scotoma (JXS), a central defect in the ipsilateral eye with temporal field loss in the contralateral eye. In this study, we investigated whether the pattern of VF loss in patients with chiasmal compression predicted the appearance of the causative lesion on neuroimaging and described the clinical presentation of these patients with different types of VF defect. Retrospective chart review of patients seen in tertiary neuro-ophthalmology practice over 6 consecutive years with lesions abutting or displacing the OC was performed. Lesion size and location relative to the OC on neuroimaging was determined and correlated with VF defects as well as optical coherence tomography (OCT) of the peripapillary retinal nerve fiber layer and macular ganglion cell complex (GCC). Fifty-three patients were enrolled. VFs demonstrated JXS (n = 18), BTH (n = 14), monocular VF defect (n = 4), and no VF defect (n = 17); 64.7% of cases with normal VFs had radiologic OC compression. Lesion volume was highest in the JXS group, and these patients also had the poorest presenting visual acuity. All patients with JXS showed involvement of the ON-OC junction; however, not all cases showed compression of the OC from the nasal direction (15 of 18), and 17 of 18 also showed compression of one or both prechiasmatic ONs. Compression of the ON-OC junction was also seen in 79% of BTH, 100% of monocular VF defect, and 59% of no VF defect cases. Fifty percent of patients with normal VFs already had thinning of the GCC on OCT. GCC thinning was most pronounced nasally in the BTH group, but diffuse bilateral thinning was found in 38% of cases compared with 60% of JXS. VFs improved in 6 of 6 patients with BTH but only in 5 of 8 JXS cases after treatment. JXS is more often seen with larger lesions and when there is compression of both the prechiasmatic ON and ON-OC junction. These patients have worse presenting visual acuity and poorer outcomes. Not all patients with radiologic compression had VF defects, although 50% of patients with normal VFs had evidence of compression on the macular GCC analysis, emphasizing the importance of macular OCT in the evaluation of patients with lesions involving the OC.

Classification of Multiple Visual Field Defects using Deep Learning

In this work, a custom deep learning method is proposed to develop a detection of visual fields defects which are the markers for serious optic pathway disease. Convolutional Neural Networks (CNN) is a deep learning method that is mostly used in images processing. Therefore, a custom 10 layers of CNN algorithm is built to detect the visual field defect. In this work, 1200 visual field defect images acquired from the Humphrey Field Analyzer 24–2 collected from Google Image have been used to classify 6 types of visual field defect. The defect patterns are including defects at central scotoma, right/left/upper/lower quadratopia, right/left hemianopia, vision tunnel, superior/inferior field defect and normal as baseline. The custom designed CNN is trained to discriminate between defect patterns in visual field images. In the proposed method, a mechanism of pre-processing is included to improve the classification of visual field defects. Then, the 6 visual field defect patterns are detected using a convolutional neural network. The dataset is evaluated using 5-fold cross-validation. The results of this work have shown that the proposed algorithm achieved a high classification rate with 96%. As comparison, traditional machine learning Support Vector Machine (SVM) and Classical Neural Network (NN) is chose and obtained classification rate at 74.54% and 90.72%.

Pattern of Visual Field Defects in Newly Diagnosed Primary Open Angle Glaucoma Patients Attending Tertiary Care Hospital, Kathmandu, Nepal

The purpose of this study was to evaluate the location and pattern of visual field defects as measured by Humphrey Field Analyzer (HFA 24-2) in newly diagnosed primary open angle glaucoma (POAG) attending tertiary care hospital. This was a cross sectional, descriptive study. One hundred and four eyes of 52 patients who fulfilled the inclusion criteria during one year were included. They were classified as mild, moderate and severe glaucoma according to severity. Paracentral scotoma in superotemporal and superonasal region was the most frequent visual field defect observed in mild glaucoma. Superior arcuate defect and double arcuate defect was commonly seen among moderate and severe stages of POAG respectively. There was a significant association between severity of glaucoma and pattern of visual field defect (p=0.000). The superior hemifield was affected twice more than the inferior hemifield in newly diagnosed cases of POAG.

Inter-Eye Association of Visual Field Defects in Glaucoma and Its Clinical Utility.

PurposeTo investigate intereye associations of visual field (VF) defects.MethodsWe selected 24-2 VF pairs of both eyes from 63,604 patients tested on the same date with mean deviation (MD) ≥ −12 dB. VFs were decomposed into one normal and 15 defect patterns previously identified using archetypal analysis. VF pattern weighting coefficients were correlated between the worse and better eyes, as defined by MD. VF defect patterns (weighting coefficients > 10%) in the better eye were predicted from weighting coefficients of the worse eye by logistic regression models, which were evaluated by area under the receiver operating characteristic curve (AUC).ResultsIntereye correlations of archetypal VF patterns were strongest for the same defect pattern between fellow eyes. The AUCs for predicting the presence of 15 defect patterns in the better eye based on the worse eye ranged from 0.69 (superior nasal step) to 0.92 (near total loss). The AUC for predicting superior paracentral loss was 0.89. Superior paracentral loss in the better eye was positively correlated with coefficients of superior paracentral loss, central scotoma, superior altitudinal defect, nasal hemianopia, and inferior paracentral loss in the worse eye, and negatively correlated with coefficients of the normal VF, superior peripheral defect, concentric peripheral defect, and temporal wedge. The parameters are presented in the descending order of statistical significance.ConclusionsVF patterns of the worse eye are predictive of VF defects in the better eye.Translational RelevanceOur models can potentially assist clinicians to better interpret VF loss under measurement uncertainty.

Programme choice for perimetry in neurological conditions (PoPiN): a systematic review of perimetry options and patterns of visual field loss

BackgroundVisual field loss occurs frequently in neurological conditions and perimetry is commonly requested for patients with suspected or known conditions. There are currently no guidelines for how visual fields in neurological conditions should be assessed. There is a wide range of visual field programs available and the wrong choice of program can potentially fail to detect visual field loss. We report the results of a systematic review of the existing evidence base for the patterns of visual field loss in four common neurological conditions and the perimetry programs used, to aid the design of future research and clinical practice guidelines.MethodsA systematic search of the literature was performed. The inclusion criteria required studies testing and/or reporting visual field loss in one or more of the target conditions; idiopathic intracranial hypertension, optic neuropathy, chiasmal compression and stroke. Scholarly online databases and registers were searched. In addition articles were hand searched. MESH terms and alternatives in relation to the four target conditions and visual fields were used. Study selection was performed by two authors independently. Data was extracted by one author and verified by a second.ResultsThis review included 330 studies; 51 in relation to idiopathic intracranial hypertension, 144 in relation to optic neuropathy, 105 in relation to chiasmal compression, 21 in relation to stroke and 10 in relation to a mixed neuro-ophthalmology population.ConclusionsBoth the 30–2 and 24–2 program using the Humphrey perimeter were most commonly reported followed by manual kinetic perimetry using the Goldmann perimeter across all four conditions included in this review. A wide variety of other perimeters and programs were reported. The patterns of visual field defects differ much more greatly across the four conditions. Central perimetry is used extensively in neurological conditions but with little supporting evidence for its diagnostic accuracy in these, especially considering the peripheral visual field may be affected first whilst the central visual field may not be impacted until later in the progression. Further research is required to reach a consensus on how best to standardise perimetry for neurological conditions.

Evaluation of visual field sensitivity and optical coherence tomography in pseudoglaucomatous optic neuropathy

Objective The aim of the study was to evaluate the protocol of optical coherence tomography (OCT) and visual field (VF) sensitivity testing in the diagnosis of pseudoglaucomatous optic neuropathy and avoid misdiagnosis with glaucoma. Background Pseudoglaucoma is defined as false or deceptive glaucoma with or without ocular damage. Multiple entities can produce 'pseudoglaucomatous optic disc' and care should be taken to differentiate it from glaucomatous eyes that, for the present, do not reveal symptoms of glaucoma.Patients who have pseudoglaucomatous optic disc cupping should be invitigated well. Patients and methods This study was conducted on 39 eyes (of 24 patients) to assess the protocol of OCT and VF sensitivity testing in the diagnosis of pseudoglaucomatous optic neuropathy. Results In this study the average age was significantly lower in patients with pseudoglaucomatous cupping (24 years). Best-corrected visual acuity (BCVA) did not significantly decrease in patients after pseudoglaucomatous optic neuropathy. Patients with nonglaucomatous optic nerve cupping had better VF mean deviation and pattern standard deviation. Eyes with pseudoglaucomatous optic nerve cupping had a lower mean retinal nerve fiber layer (RNFL) in both the nasal and temporal quadrants. Conclusion VF sensitivity and OCT appear to be of value in the evaluation of pseudoglaucomatous optic disc cupping. The pattern of RNFL loss varied on the basis of etiology and appeared more diffuse in nonglaucomatous optic nerve cupping. The nasal and temporal RNFL thicknesses were lower in patients with nonglaucomatous optic nerve cupping compared with the reported results in glaucoma patients. The pattern of VF defect varied depending on etiology and the VF mean deviation and pattern standard deviation were better compared with the results reported in glaucoma patients.

English

INTRODUCTION: Pituitary adenoma is a benign tumour that originates from the adenohypophyseal cells of the anterior lobe of pituitary gland. It accounts for 12% to 15% of all intracranial tumours. A spectrum of visual manifestations are seen with these tumours, ranging from the absence of any visual symptoms to severe visual field defects and loss of vision The clinical manifestations depend on the cell type of the tumour, hypo or hypersecretion of hormones, direction of local spread and compression of adjacent structures. Pituitary adenomas are of 2 types according to the size : microadenomas (≤10 mm) and macroadenomas (>10 mm). In comparison to men, women have a 2-fold increased risk of developing pituitary adenomas. Pituitary adenoma is a benign tumour, however, it has a tendency of recurrence. Clinical features of adenomas are either due to hypersecretion or hyposecretion of hormones or compression of pituitary adenoma to the surrounding structures. Pituitary gland is situated in the sella turcica, 10–13 mm below the optic chiasm. Therefore, when it increases in size, it can easily compress the optic nerve fibres at the chiasma. AIM OF THE STUDY: PRIMARY OBJECTIVES: 1. To study the various ophthalmic manifestations in cases of pituitary tumors. 2. To analyse the proportion of cases presenting with ophthalmic manifestations in cases diagnosed as pituitary adenoma on radiological imaging. SECONDARY OBJECTIVES: 1. To analyse the sensory visual disturbances like degree of visual loss, pattern of visual field defects and ocular motility defects, in diagnosed cases of pituitary adenomas. MATERIALS AND METHODS: Patients who are diagnosed with pituitary adenoma on radiological imaging, presenting in Squint and Neuro-ophthalmology services will be registered and evaluated during the study period. A detailed history of the patient, evaluation of visual acuity on a Snellen chart, extraocular movement and pupillary assessment, colour vision, visual field examination by 32 program on octopus field analyser octopus, slit lamp examination, and fundus examination will be done. INCLUSION CRITERIA: 1. Patients diagnosed as having pituitary tumour on radiological imaging 2. Age 25- 65 years. EXCLUSION CRITERIA: 1. Patients with other ocular pathologies affecting visual fields such as glaucoma, optic neuritis, retinitis pigmentosa. 2. Patients with pre-existing defective vision to due to other causes. 3. Patients with ocular media opacities. 4. Patients physically or mentally unfit for detailed ocular examination. SUMMARY: • Commonest Age group was more than 50 years (60%). Mean age 50.6 years. • Females were more commonly affected (72%). • Headache was the most common presenting complaint (80%). • Most of the Patients (62%) had visual acuity between 6/6 to 6/12. • Patients had Pituitary macroadenomas in 96% of cases compared to microadenomas. • Bitemporal hemianopia was the commonest visual field defect (57.9%). • 24% of the patients had no visual field defect. • 16% Patients had features of Optic Atrophy on Fundus examination. CONCLUSION: As the primary goal in the management of pituitary adenoma revolves around restoration of visual loss, a neuro-ophthalmic evaluation is essential for early detection, planning treatment and subsequent follow up. Although a bitemporal visual field defect is a pathognomonic ophthalmic finding in cases of pituitary adenomas, various other clinical features like headache, ophthalmoplegia, sensory visual disturbances, and other field defects were also noted in our study. Hence, a thorough clinical evaluation is warranted in pituitary adenomas.

PROGRESSION OF VISUAL FIELDS IN POSTERIOR CORTICAL ATROPHY MIRRORS THAT OF COGNITIVE DEFICITS

The significance of visual field defects (VFD) in posterior cortical atrophy (PCA) has been questioned in face of coexisting higher-order visual disturbances. The relationship between pattern of VFDs and that of cognitive deficits may give insight into the mechanism of VFDs in PCA. Twenty-one patients with PCA had visual field tests performed using Humphrey automated perimetry at baseline and follow-up (mean duration 2.5 years; number of assessments 2–4). Mean deviation (MD) per hemifield was calculated and the ratio between MD in the right and left hemifield (R/LMDratio) established for every assessment. Cognitive measures consisted of scores created to summarise performance on tests of unilateral (Object Perception (OP); Space Perception (SP); Spelling; Arithmetic) and bilateral cognitive functions (Shape Detection (SD); Figure-Ground Discrimination (FGD)). Cognitive scores were compared with R/LMDratio at baseline using Spearman's correlation. Progression in cognitive tests was analysed according to time and contemporary R/LMDratio using mixed model linear regression. All patients had abnormal HFA at presentation, consisting of incomplete homonymous hemianopia (HH) more marked in one hemifield in all but one patient. The more affected hemifield was the left in 14 patients (66%). At baseline R/LMD did not correlate with score on OP (ρ=0.23,p<0.3), SP (ρ=0.12, p<0.6), Arithmetic (ρ =-0.24, p<0.28), or Spelling (ρ =-0.25, p<0.28). On the longitudinal analysis, increment of one unit in RLMDratio was associated with decrement of -0.78 in Spelling (p<0.01) and -0.83 in Arithmetic (p<0.02), but had no effect on OP or SP (slope 0.001, p<0.9; and 0.01, p<0.9, respectively). Increasing 1 unit on the log of RLMDratio absolute value (RLMD approached 1) was associated with decline of 0.73 (p<0.03) in FGD and 0.55 (p<0.04) in SD. Predominant right HH was associated with greater decline on cognitive functions relying on the left hemisphere, suggesting that VFDs result from extension of degeneration into the contralateral occipital lobe. This was further supported by the association between bilateral VFDs and deterioration on bilateral occipital lobe functions. Predominant left HH did not correlate with greater right hemisphere deficits, which may be explained by the occurrence of the latter in all patients, as a consequence of PCA case definition.

Association of Glaucoma-Susceptible Genes to Regional Circumpapillary Retinal Nerve Fiber Layer Thickness and Visual Field Defects.

To examine the associations of the earlier reported glaucoma-related genes to the regional circumpapillary retinal nerve fiber layer thicknesses (cpRNFLTs) and corresponding visual field defects. We studied 756 patients with primary open-angle glaucoma (POAG) and 3094 normal controls. Each participant was genotyped for nine single nucleotide polymorphisms (SNPs) of four glaucoma-susceptible genes: the CDKN2B(AS1), TMCO1, CAV1/CAV2, and SIX1/SIX6 genes. For the SNPs that were significantly associated with the POAG case-control analyses, the associations of SNP genotypes with the cpRNFLTs of 12 sectors were also analyzed, and then finer assessments were performed using 768 points of the cpRNFLT and corresponding visual field defect sensitivities using case-only subjects. We confirmed that there was a significant association of the CDKN2B(AS1) gene to POAG. For the suggested region-specific associations of these genes with the 12-sectored cpRNFLT, a 768-point cpRNFLT examination showed that rs4977756 near CDKN2B had significant signal peaks in the temporal region at 330° to 360° and 0° to 30° (maximum β = 2.92, P = 2.9 × 10-5 at 351.1° and maximum β = 3.97, P = 2.2 × 10-4 at 23.4°, respectively). These region-specific signals were validated by the corresponding visual field defect patterns of the paracentral/lower hemifield (P < 0.05). Genetic association analyses using the cpRNFLT with 768 points suggest that the CDKN2B gene was associated with paracentral/lower hemifield scotomas. Our regional association analyses on cpRNFLT allow detailed characterization of glaucoma-related genes and should be a new target for genomic studies for glaucoma endophenotypes.

Comprehensive review of visual defects reported with topiramate.

ObjectiveThe objective of this study was to analyze clinical patterns of visual field defects (VFDs) reported with topiramate treatment and assess possible mechanism of action (MOA) for antiepileptic drug (AED) associated VFDs.MethodsA comprehensive topiramate database review included preclinical data, sponsor’s clinical trials database, postmarketing spontaneous reports, and medical literature. All treatment-emergent adverse events (TEAEs) suggestive of retinal dysfunction/damage were summarized. Relative risk (RR) was computed from topiramate double-blind, placebo-controlled trials (DBPCTs) data.ResultsPreclinical studies and medical literature review suggested that despite sharing gamma-aminobutyric acid (GABA)-ergic MOA with other AEDs, topiramate treatment was not associated with VFDs. TEAEs suggestive of retinal dysfunction/damage were observed in 0.3%–0.7% of adults and pediatric patients with topiramate (N=4,679) versus ≤0.1% with placebo (N=1,834) in DBPCTs for approved indications (epilepsy and migraine prophylaxis); open-label trials (OLTs) and DBPCTs for investigational indications had similar incidence. Overall, 88% TEAEs were mild or moderate in severity. Serious TEAEs were very rare (DBPCTs: 0%; OLTs: ≤0.1%), and most were not treatment limiting, and resolved. The most common visual TEAEs (approved indications) were VFD, scotoma, and optic atrophy. The incidence of TEAEs in DBPCTs (approved and investigational indications) was higher in topiramate-treated (N=9,169) versus placebo-treated patients (N=5,023; 0.36% vs 0.24%), but the RR versus placebo-treated patients was not significant (RR: 1.51 [95% confidence interval: 0.78, 2.91]).ConclusionVFDs do not appear to be a class effect for AEDs with GABA-ergic MOA. The RR for VFDs is not significantly different between topiramate and placebo treatment.

Does the World Health Organization criterion adequately define glaucoma blindness?

PurposeBlindness in glaucoma is difficult to assess with merely the use of the current World Health Organization (WHO) definition (a visual field restricted to 10° in a radius around central fixation), as this criterion does not cover other types of visual field loss that are encountered in clinical practice and also depict blindness. In this study, a 5-point ordinal scale was developed for the assessment of common visual field defect patterns, with the purpose of comparing blindness as outcome to the findings with the WHO criterion when applied to the same visual fields. The scores with the two methods were compared between two ophthalmologists. In addition, the variability between these assessors in assessing the different visual field types was determined.MethodsTwo glaucoma specialists randomly assessed a sample of 423 visual fields from 77 glaucoma patients, stripped of all indices and masked for all patient variables. They applied the WHO criterion and a 5-point ordinal scale to all visual fields for the probability of blindness.ResultsThe WHO criterion was mostly found applicable and in good agreement for both assessors to visual fields depicting central island of vision or a temporal crescent. The percentage of blindness scores was higher when using the ordinal scale, 21.7% and 19.6% for assessors A and B, respectively, versus 14.4% and 11.3% for the WHO criterion. However, Kappa was lower, 0.71 versus 0.78 for WHO.ConclusionsThe WHO criterion is strictly applied and shows good agreement between assessors; however, blindness does not always fit this criterion. More visual fields are labeled as blind when a less stringent criterion is used, but this leads to more interobserver variability. A new criterion that describes the extent, location, and depth of visual field defects together with their consequence for the patient’s quality of life is needed for the classification of glaucoma blindness.

The Association between Corneal Biomechanical Properties and Initial Visual Field Defect Pattern in Normal Tension Glaucoma

The Association between Corneal Biomechanical Properties and Initial Visual Field Defect Pattern in Normal Tension Glaucoma

Clinical manifestations of parasellar mass

PurposeThis study was purposed to make comparative analysis on various clinical findings of parasellar mass which was diagnosed by ophthalmologist.MethodsFor 51 patients diagnosed as parasellar mass (23 males, 28 females), we reviewed vision, clinical symptoms, visual fields, imaging study.ResultsAt the first visit, the patient's most common chief complain was decreased visual acuity or blurred vision (41 patients) and other symptoms include visual field defect (7 patients) and diplopia (3 patients). Corrected visual acuity was varied from 1.0 to &lt;0.01. Variable visual field defect pattern was noted (normal to complete defect). But usually bilateral temporal hemianopia was the most common finding in visual field test. In some cases, diplopia was the only symptom of mass.ConclusionsWhen a patient complains visual field defects and shows unilateral or bilateral temporal visual field defect in visual field test, it was easy to suspect parasellar mass. But no visual field defect in patient with tumor is also exist. So in patients who complain unexplained visual discomfort with normal visual acuity or normal visual filed, we must suspect tumor and consider neurologic image study in order to rule out the tumor.