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Auto perimetry
1.
INTERPRETATION OF AUTOMATED PERIMETRY
2.
© Thomas R Automated
perimetry
3.
© Thomas R Automated
perimetry I. Perimetry logic II. Identifying field defects III. Criteria for glaucomatous defects IV. Detecting glaucomatous progression V. Advanced field defects
4.
© Thomas R Bracketing
strategy B A
5.
© Thomas R Normal
thresholds • Mean threshold in disease-free fields • In a given age group • At a given location in the visual field • Mean normal values are stored in the automated perimeter and compared against patient data
6.
© Thomas R Computers
and ease of interpretation Sensitivity + Simple set of rules Computer Diagnosis
7.
© Thomas R Perimeter
logic (1) • Sensitivity determined at each location • Normal range developed • Normal range is arbitrary – Includes the values of 95% of the normal population
8.
© Thomas R Perimeter
logic (2) • ‘Abnormal’ values include the lowest 5% of those in normal individuals • Therefore, 5% of normal individuals will be labelled abnormal ‘Abnormal’ is not the same as diseased
9.
© Thomas R Perimeter
logic (3) • General population – 100 tested • 1% glaucoma; 99% normal • Six will have abnormal tests: • 1 glaucoma patient • 5 normal individuals
10.
© Thomas R Perimeter
logic (4) • Clinic population – 100 tested • 30% glaucoma; 70% normal • 33 will have abnormal tests • 30 glaucoma patients • 3 normal individuals
11.
© Thomas R Interpretation
is not child’s play Automated perimeters still need interpretation
12.
© Thomas R Before
interpretation … … a few principles
13.
© Thomas R Rely
on threshold tests • First real evidence of glaucoma • Detect scotoma • Detect depression of the ‘hill’ of vision • May predict visual loss
14.
© Thomas R Screening
tests • Screening • Fishing • Fatigue
15.
© Thomas R Interpreting
decibel values is just half the challenge … • False positives • False negatives • Fixation • Fluctuation • Strategy • Experience • Technicians • Artefacts
16.
© Thomas R
17.
© Thomas R Optimising
patient performance • Choose the most appropriate investigation – Test pattern and strategy • Ensure the patient is comfortably positioned – Support feet, back and arms – Adjust chin rest – Cover the other eye fully • Provide careful instructions prior to the test • Support the patient during the test • Give feedback on test performance SEAGIG. Asia Pacific Glaucoma Guidelines. 2003–2004.
18.
© Thomas R A
word about the grey scale • Never use the grey scale alone for interpretation • It is useful to educate the patient and to identify false-positive and false-negative errors
19.
‘White’ scotomas associated with
false positives © Thomas R
20.
© Thomas R
21.
‘Clover leaf’ pattern
associated with false negatives © Thomas R
22.
© Thomas R Using
the grey scale • To educate the patient • White scotomas with false positives • Clover leaf pattern with false negatives • Never interpret using the grey scale alone
23.
© Thomas R Questions •
Is there a field defect? • Is it due to glaucoma? • Is the defect progressing?
24.
© Thomas R Is
the field abnormal? • Without obvious defects, it is difficult to make a decision based on the first field • Repeat examinations provide definitive information • Never make a diagnosis based on the visual field alone
25.
Interpret the field systematically
using zones 1–8 © Thomas R
26.
2 © Thomas R AGE
57 2 FIXATION LOSSES 0/24 FALSE POS ERRORS 0/14 FALSE NEG ERRORS 1/13 QUESTIONS ASKED 449 FOVEA: 33 DB TEST TIME 13:59
27.
• Just glance
at the grey scale and move on to zones 4 & 5 • Never interpret using the grey scale alone 3 © Thomas R
28.
© Thomas R •
Point-by-point difference from the expected value for age-related normal individuals • Reveals generalised depression • Cannot confirm a scotoma • Look at the number and pattern of symbols Zone 4: total deviation
29.
© Thomas R 180°
0° 40 dB 0 30 20 10 90 60 30 0 30 60 90 Normal ‘hill’ of vision
30.
© Thomas R 180°
0° 40 dB 0 30 20 10 90 60 30 0 30 60 90 Generalised depression
31.
© Thomas R 180°
0° 40 dB 0 30 20 10 90 60 30 0 30 60 90 Generalised depression with ‘hidden’ localised scotoma
32.
© Thomas R 180°
0° 40 dB 0 30 20 10 90 60 30 0 30 60 90 Pattern deviation plot: scotoma revealed after adjusting for generalised depression
33.
© Thomas R •
Reveals focal defects after adjusting for overall depression (or elevation) of the hill of vision • Confirms a scotoma :: :: Zone 5: pattern deviation
34.
Examples of total
and pattern deviation plots in different situations
35.
© Thomas R Normal
‘hill’ of vision
36.
© Thomas R ‘Normal’
hill of vision with localised scotoma SEAGIG. Asia Pacific Glaucoma Guidelines. 2003–2004. 180° 0° 40 dB 0 30 20 10 90 60 30 0 30 60 90 ‘Normal’ hill of vision with localised scotoma
37.
© Thomas R Generalised
depression with ‘hidden’ localised scotoma
38.
© Thomas R Generalised
depression
39.
© Thomas R
40.
© Thomas R MD
–2.18 dB PSD 4.63 dB; p < 1% SF 1.24 dB CPSD 4.44 dB; p < 0.5% • All the information from all the points tested is reduced to single numbers Global indices MD, mean deviation; PSD, pattern standard deviation; SF, short-term fluctuation; CPSD, corrected PSD.
41.
• Both MD
and PSD are derived from the total deviation plot • However, they provide different types of information © Thomas R
42.
© Thomas R •
Average of all the numbers in the total deviation plot • Indicates overall deviation of the visual field from normal • Positive numbers indicate an ‘elevated’ field • Negative numbers indicate a ‘depressed’ field Global indices: mean deviation (1) MD –2.18 dB PSD 4.63 dB; p < 1% SF 1.24 dB CPSD 4.44 dB; p < 0.5%
43.
© Thomas R •
Provides similar information to total deviation • Cannot confirm the presence of a scotoma Global indices: mean deviation (2) MD –2.18 dB PSD 4.63 dB; p < 1% SF 1.24 dB CPSD 4.44 dB; p < 0.5%
44.
© Thomas R •
Also derived from the total deviation plot • Indicates the degree to which the numbers differ from each other • Highlights ‘roughness’ or ‘pot-holes’ in the hill of vision Global indices: pattern standard deviation (1) MD –2.18 dB PSD 4.63 dB; p < 1% SF 1.24 dB CPSD 4.44 dB; p < 0.5%
45.
© Thomas R Global
indices: pattern standard deviation (2) MD –2.18 dB PSD 4.63 dB; p < 1% SF 1.24 dB CPSD 4.44 dB; p < 0.5% • Provides similar information to the pattern deviation • Calls attention to scotomas
46.
© Thomas R 28 28
29 33 32 32 32 30 30 33 32 29 31 28 30 29 29 29 21 26 2728293332 31 24 29 31 30 2928 26 29 29 27 26 26 25 28 29 32 32 32 32 29 30 32 31 29 31 25 28 29 25 20 27 26 272803434 32 29 32 33 30 3032 25 27 29 28 23 29 (31) (32) (32) (30) (31) (30) (33) (30) (31) (33) • Intra-test error in threshold determination • Standard deviation of 10 predetermined points that are each tested twice Global indices: short-term fluctuation
47.
© Thomas R Global
indices: corrected pattern standard deviation • CPSD is PSD corrected for the SF – If SF is due to unreliability, then CPSD is better – If SF is due to pathology, then PSD is better
48.
© Thomas R MD Total deviation
plot PSD Pattern deviation plot Generalised depression Can suspect a scotoma Review of key points Local irregularity Confirms scotoma
49.
Glaucoma Hemifield Test ©
Thomas R
50.
© Thomas R Zone
7: Glaucoma Hemifield Test 44 5 3 2 1
51.
© Thomas R GHT,
Glaucoma Hemifield Test.
52.
© Thomas R
53.
8 © Thomas R
54.
• Never rely
on the grey scale alone to make a diagnosis • Never rely on the visual field alone to make a diagnosis • Always correlate with the clinical findings © Thomas R
55.
© Thomas R Questions Is
there a field defect? • Is it due to glaucoma? • Is the defect progressing?
56.
© Thomas R Glaucomatous
defects • Characteristics of glaucomatous defects: – Asymmetrical across the horizontal midline* – Located in the mid-periphery* (5–25 degrees from fixation) – Reproducible – Not attributable to other pathology – Localised – Correlating with the appearance of the optic disc and neighbouring areas * Applicable to early/moderate cases. SEAGIG. Asia Pacific Glaucoma Guidelines. 2003–2004.
57.
© Thomas R Criteria
for glaucomatous defects (1) Pattern deviation plot • ≥ 3 non-edge points with p < 5% • One point with p < 1% • Cluster in arcuate area
58.
© Thomas R Criteria
for glaucomatous defects (2) CPSD or PSD depressed with p < 5%
59.
© Thomas R Criteria
for glaucomatous defects (3) Abnormal GHT
60.
© Thomas R Three
criteria for glaucomatous defects* 1. Pattern deviation plot – ≥ 3 non-edge points with p < 5% – One point with p < 1% – Cluster in arcuate area 2. CPSD or PSD depressed with p < 5% 3. Abnormal GHT *Anderson DR, Patella VM. Automated Static Perimetry. 2nd Edn. St Louis: Mosby, 1999.
61.
• Try interpreting this
visual field, going from zones 1–8 © Thomas R
62.
2 2 Visual acuity should
correlate with the foveal threshold © Thomas R
63.
• Continue interpreting this visual
field: zones 3–8 • Remember: no more than a glance at the grey scale © Thomas R
64.
© Thomas R Revision:
typical cataract
65.
© Thomas R Revision:
typical glaucoma
66.
© Thomas R Revision:
glaucoma and cataract
67.
© Thomas R Does
this patient have glaucoma? (1) Only if the defects are repeatable and correlate with disc and clinical findings
68.
© Thomas R Does
this patient have glaucoma? (2) Only if the defects are repeatable and correlate with disc and clinical findings
69.
© Thomas R Questions Is
there a field defect? Is it due to glaucoma? • Is the defect progressing?
70.
© Thomas R Principle •
Is there a field defect? • Is it due to glaucoma? • Is the defect progressing? – Compare to selected baseline – Discard learning fields from baseline – Recognise ‘false’ progression
71.
© Thomas R False
progression • Learning curve • Long-term fluctuation • Artefacts • Patient factors • Pupil size
72.
Pupil: 1 mm ©
Thomas R
73.
Pupil: 2.5 mm ©
Thomas R
74.
© Thomas R Detecting
change • Change analysis – box plot • Overview programme • Glaucoma progression analysis™ (GPA™) 1. Select appropriate baseline 2. Discard learning fields from baseline
75.
© Thomas R Overview
programme • Sequential series of fields for the same patient over a period of time • Has all the single field information, including total and pattern deviation plots • Tells us at a glance what is happening and allows us to deduce WHY it is happening
76.
Fluctuation over time ©
Thomas R
77.
Overview: the patient
developed a cataract, which was extracted. Note that the pattern deviation plot remains clear. © Thomas R
78.
Overview: glaucoma is
progressing. Both the total and pattern deviation plots show worsening. © Thomas R
79.
© Thomas R Overview programme
shows progression Full threshold SITA standard SITA, Swedish Interactive Threshold Algorithm.
80.
© Thomas R Overview programme
shows progression • SITA is different from full threshold • Can't compare apples to oranges • Fields may fluctuate
81.
© Thomas R Glaucoma
Progression Analysis™* • GPA™ is now in clinical use • Change is based on the pattern deviation plot • Compatible with both SITA and full threshold (baseline only) *Carl Zeiss Meditec.
82.
© Thomas R
83.
GPA™ Right eye: baseline © Thomas
R GPATM, Glaucoma Progression AnalysisTM.
84.
GPA™ Right eye: follow-up © Thomas
R GPATM, Glaucoma Progression AnalysisTM.
85.
© Thomas R 3
or more points deteriorate in at least 2 consecutive tests © Thomas R
86.
3 or more
points deteriorate in at least 3 consecutive tests © Thomas R
87.
GPA™ Left eye: baseline © Thomas
R GPATM, Glaucoma Progression AnalysisTM.
88.
GPA™ Left eye: follow-up © Thomas
R GPATM, Glaucoma Progression AnalysisTM.
89.
© Thomas R
90.
© Thomas R Diagnosis
of visual field progression • Different for research purposes – Set criteria in isolation • Clinical follow-up scenario – Other criteria (IOP, disc changes) to consider – A corresponding repeatable change is sufficient – If in doubt, REPEAT • Baseline fields are not constant – Select accordingly
91.
Don’t forget to
discard ‘learning’ fields from baseline © Thomas R
92.
© Thomas R Follow-up
of advanced field defects
93.
Advanced field defect Why
is the pattern deviation plot not showing a defect? © Thomas R
94.
Not enough points
with sensitivity to produce the pattern deviation plot © Thomas R
95.
Follow-up with a
10–2 programme – now there are enough sensitive points to produce a pattern deviation plot © Thomas R
96.
Advanced defect and/or low
sensitivities – follow-up with a size V target Disadvantage: we lose statistical help for interpreting the total and pattern deviation plots © Thomas R
97.
© Thomas R More
advanced defects: follow with macular programme
98.
Macular programme in advanced
glaucoma © Thomas R
99.
Size V target:
macular split Macular split (0 dB) next to the fovea with a size V target may predict ‘wipe out’ © Thomas R
100.
© Thomas R Recent
developments: SITA • Asks smart questions • Gold standard • More abnormal points on pattern deviation • Shallower defects • Significant because of less variability
101.
SITA is interpreted
in the same 8 zones as previously described © Thomas R SITA, Swedish Interactive Threshold Algorithm.
102.
SITA uses the
same criteria to identify a glaucomatous field defect © Thomas R SITA, Swedish Interactive Threshold Algorithm.
103.
Applying the skills Does
this field fulfil the criteria for a glaucomatous defect? Does this patient have glaucoma? © Thomas R
104.
Not unless the
field defect correlates with clinical findings Never diagnose based on the visual field ALONE © Thomas R
105.
© Thomas R Automated
perimetry: warning Sophisticated techniques and elaborate data printouts should not seduce us into a false sense of security or a misplaced belief in the validity or reliability of automated perimetry* *Zalta AH. Ophthalmology 1989; 96: 1302–11.
106.
INTERPRETATION OF OCTOPUS FIELDS
107.
© Thomas R Test
parameters – Octopus vs. HFA 4–2 dB bracketing strategy SITA standard SITA fast 4–2–1 dB bracketing strategy Dynamic Tendency oriented perimetry (TOP) Test strategies 0–40 dB0–40 dBMeasuring range Goldmann I–V 200 ms 10,000 asb Goldmann III and V 100 ms 4800 asb Stimulus size Stimulus duration Luminance for 0 dB 10 cd/m2 (31.5 asb)10 cd/m2 (31.4 asb)Background luminance Aspherical bowlDirect projectionBowl type HFA 700 seriesOctopus 300Parameter Fankhauser F et al. Automated Perimetry: Visual Field Digest. 5th Edn. Köniz: Haag-Streit AG, 2004.
108.
[[Credit line to
be added]] Probability plots Comparison tables Grey scale Patient data and refraction Strategy and test parameters Actual values Bebie (defect) curve Deviation Global indices RP: permission requested
109.
© Thomas R Octopus
global indices • MS Mean sensitivity – Average of all measured values • MD Mean defect – Average of all values corrected for age • LV Loss variance – Equivalent to PSD • SF Short-term fluctuation • CLV ‘Corrected’ loss variance – Equivalent to corrected PSD • RF Reliability factor
110.
© Thomas R Is
the visual field abnormal? • Octopus criteria for a visual field defect1 – MD greater than 2 dB – LV greater than 6 dB – At least 7 points with sensitivity decreased by ≥ 5 dB, three of them being contiguous • How do these compare to HFA criteria? 1. Morales J et al. Ophthalmology 2000; 107: 134–42.
111.
© Thomas R HFA
criteria for glaucomatous defects* 1. Pattern deviation plot – ≥ 3 non-edge points with p < 5% – One point with p < 1% – Cluster in arcuate area 2. CPSD or PSD depressed with p < 5% 3. Abnormal GHT *Anderson DR, Patella VM. Automated Static Perimetry. 2nd Edn. St Louis: Mosby, 1999.
112.
Comparison of Octopus
and HFA fields from a single patient © Sihota R
113.
© Thomas R Patient
data, strategy and test parameters © Sihota R
114.
© Sihota R Grey
scale
115.
© Thomas R©
Sihota R Octopus: comparison tables Phase I Phase 2 Mean # 59 59 59 MS 21.8 18.6 20.2 MD 6.8 10.1 8.5 LV 46.6 73.2 51.0 CLV 42.2 SF 4.9 RF 3.1
116.
© Thomas R©
Sihota R GHT Outside normal limits MD –7.58 dB; p < 0.5% PSD 6.30 dB; p < 2% SF 2.27 dB; p < 10% CPSD 5.75 dB; p < 1% HFA: total and pattern deviation
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