Utility of CLOCK CHART binocular edition for self-checking the binocular visual field in patients with glaucoma.

BACKGROUND/AIMS: Car accidents caused by drivers unaware of their visual field (VF) defects under binocular vision have become an issue. We developed a simple self-check chart (CLOCK CHART binocular edition (CCBE)) to help patients with glaucoma recognise their abnormalities in the binocular VF and evaluated its usefulness. METHODS: The chart has four targets displayed at 10°, 15°, 20° and 25° eccentricities. The examinee gradually rotates the chart 360° clockwise. At every 30°, the examinee confirms the fixation and indicates if all four targets can be seen. This study enrolled 88 eyes of 44 patients with glaucoma (mean age, 64.4±13.1 years) and 64 eyes of 32 visually normal individuals (mean age, 32.0±8.4 years). Except the CCBE test, static VF testing using the Humphrey field analyser (HFA) Swedish Interactive Threshold Algorithm-Standard 30-2 and binocular Esterman programmes was also performed for the subjects with glaucoma. RESULTS: VF abnormality was defined as two or more contiguous points with a sensitivity of <10 dB within the central 30°. The CCBE test had sensitivities of 85% and 82% with respect to the HFA and Esterman results, respectively. We also used the British VF standards for Group 1 (car/motorcycle) drivers, and a sensitivity of 88% was obtained for the CCBE. The chart had a specificity of 100% for the visually normal subjects. CONCLUSION: The CCBE test enables drivers with glaucoma to notice their VF abnormalities under binocular condition. The application of this simple self-check method appears promising for occasions such as driver licensing.

Distribution and Progression of Visual Field Defects With Binocular Vision in Glaucoma.

PURPOSE: To evaluate the distribution and progression of glaucomatous visual field (VF) defects with binocular vision. PATIENTS AND METHODS: Subjects were 167 patients (average age, 67±10.7 y) with glaucoma who received the Humphrey 24-2 VF test (SITA-Standard) for the 2 eyes. Using the Best Location Algorithm, patient's binocular integrated VF (IVF) was calculated from their Humphrey 24-2 results. Of 167, 77 subjects (average age, 68±11.0 y) also underwent monocular/binocular Humphrey Esterman tests. Patient's stage of glaucomatous VF loss was classified by the Esterman Disability Score for each test, and the distribution and progression of the defects with binocular vision was evaluated for each stage. The frequencies of the defects in the upper and lower halves of the VF were also investigated. RESULTS: With the IVF, the glaucomatous VF defects were most frequently found around the Mariotte blind spots and the Bjerrum areas and extended to the periphery. With the binocular Humphrey Esterman VF, the defects were most frequently found around the bitemporal and Bjerrum areas. The IVF results showed 31%, 49%, and 20% of the patients with the earliest glaucoma having defects in the upper, lower, and both halves of the VF, respectively. CONCLUSIONS: Glaucomatous VF defects with binocular vision were frequently found at the Mariotte blind spots in the central VF and around the bitemporal areas in the periphery. They appeared to have distributions and progression different from those of the defects with monocular vision previously reported.

Test Conditions in Macular Visual Field Testing in Glaucoma.

PURPOSE: The purpose of this study is to evaluate the suitable visual field (VF) test conditions (target size, test type, and eccentricity) for the macular region, we investigated the correlations between the ganglion cell layer (GCL) thickness and 6 VF test results. METHODS: We tested 32 eyes of patients (61.1±9.2 y) with preperimetric (6), early-stage (16), and moderate-stage (10) glaucoma. The VF tests included 3 SAP (the 10-2 HFA using SITA with target size III [HFA SITA (III)], full threshold with size III [HFA FULL (III)] and size I [HFA FULL (I)]) and 3 visual function-specific perimetry tests (the 10-2 SWAP, 10-2 flicker, and 10-2 Humphrey Matrix). The GCL and inner plexiform layer (GCL+IPL) thickness was measured by Spectral Domain Optical Coherence Tomography (SD-OCT) with a macular 7×7 mm cube scan (3D OCT-2000, Topcon). The coefficient of determination (r) for the correlation between visual sensitivity and the GCL+IPL thickness was calculated for each test at eccentricities 0 to 5 degrees, 5 to 7 degrees, and 7 to 10 degrees using linear and quadratic regressions. RESULTS: All 6 tests showed the strongest correlation with the GCL+IPL thickness at 5 to 7 degrees. The respective r (linear) and R (quadratic) for HFA SITA (III), HFA FULL (III), HFA FULL (I), SWAP, Flicker, and Matrix were (0.40, 0.50), (0.43, 0.53), (0.44, 0.46), (0.51, 0.51), (0.33, 0.34), and (0.52, 0.52). CONCLUSIONS: As compared with the frequently-used SAP with a size III, SAP with size I and the function-specific perimetry tests (especially the Matrix) could be more suitable for testing the macular region.

Effects of head tilt on visual field testing with a head-mounted perimeter imo.

PURPOSE: A newly developed head-mounted perimeter termed "imo" enables visual field (VF) testing without a fixed head position. Because the positional relationship between the subject's head and the imo is fixed, the effects of head position changes on the test results are small compared with those obtained using a stationary perimeter. However, only ocular counter-roll (OCR) induced by head tilt might affect VF testing. To quantitatively reveal the effects of head tilt and OCR on the VF test results, we investigated the associations among the head-tilt angle, OCR amplitude and VF testing results. SUBJECTS AND METHODS: For 20 healthy subjects, we binocularly recorded static OCR (s-OCR) while tilting the subject's head at an arbitrary angle ranging from 0° to 60° rightward or leftward in 10° increments. By monitoring iris patterns, we evaluated the s-OCR amplitude. We also performed blind spot detection while tilting the subject's head by an arbitrary angle ranging from 0° to 50° rightward or leftward in 10° increments to calculate the angle by which the blind spot rotates because of head tilt. RESULTS: The association between s-OCR amplitude and head-tilt angle showed a sinusoidal relationship. In blind spot detection, the blind spot rotated to the opposite direction of the head tilt, and the association between the rotation angle of the blind spot and the head-tilt angle also showed a sinusoidal relationship. The rotation angle of the blind spot was strongly correlated with the s-OCR amplitude (R2≥0.94, p<0.0001). A head tilt greater than 20° with imo causes interference between adjacent test areas. CONCLUSIONS: Both the s-OCR amplitude and the rotation angle of the blind spot were correlated with the head-tilt angle by sinusoidal regression. The rotated VF was correlated with the s-OCR amplitude. During perimetry using imo, the change in the subject's head tilt should be limited to 20°.

Evaluation of kinetic programs in various automated perimeters.

PURPOSE: Kinetic programs in four automated perimeters were evaluated and compared for their clinical usefulness using four simulated visual field (VF) patterns. METHODS: Using the results of conventional Goldmann manual kinetic perimetry (MKP), simulated fields with concentric contraction, a temporal residual island only, a small central island with a temporal island, and a ring scotoma were created. Four kinetic programs, Humphrey 750i Kinetic Test (Humphrey), OCULUS Twinfield 2 Kinetic Perimetry (OCULUS), OCTOPUS 900 Goldmann Kinetic Perimetry (OCTOPUS GKP), and Kowa AP-7000 Isopter (Kowa) were tested by the 4 simulated defect patterns using stimuli of V/4e, I/4e, I/3e, I/2e, and I/1e at speeds of 3 and 5°/s. RESULTS: Except Humphrey, OCULUS, OCTOPUS GKP, and Kowa could obtain isopters nearly comparable to those of Goldmann MKP. However, their results were considerably influenced by the examiner's skill. Besides, Humphrey had restrictions on target presentation, and OCULUS and Kowa had problems in isopter drawing and in filling in the scotoma. OCTOPUS GKP was the only method that could correctly detect and depict all four defect patterns. It also had relatively shorter test durations among the three methods excluding Humphrey, which did not have a built-in function for test duration measurement. The perimeters' test ranges for the periphery were 90° for Humphrey, OCULUS, and OCTOPUS GKP, and 80° for Kowa. CONCLUSION: To assess kinetic fields with various defect patterns, OCTOPUS GKP seems to be the most useful method.

CLOCK CHART(®): a novel multi-stimulus self-check visual field screener.

PURPOSE: CLOCK CHART(®) is a multi-stimulus-type self-check visual field screening sheet developed by our group. The test chart is rotated during the examination, and the visual field abnormalities are pointed out by the patients themselves. In this study, we evaluated the clinical usefulness of this chart in patients with glaucoma. METHODS: We studied 114 eyes of 114 glaucoma patients (average age 60.0 ± 11.1 years) and 45 eyes of 45 normal individuals (average age 45.0 ± 16.4 years) using CLOCK CHART(®). The static visual fields were obtained using the Octopus 101 G2 program and classified using the Aulhorn classification as modified by Greve (stages 0-I to IV) and by mean defect (MD; early <6 dB; moderate 6 ≤ MD ≤12 dB; severe >12 dB).The sensitivity and specificity of CLOCK CHART(®) for detecting visual field abnormalities were evaluated within the entire 25° field and at the 5°, 10°, 15°, 20°, and 25° eccentricity zones. The visual field agreement between the results of CLOCK CHART(®) and the static visual fields were also evaluated. RESULTS: In glaucomatous eyes, the sensitivity of CLOCK CHART(®) was 85, 93, and 100 % for Greve stages I, II and III-VI, respectively, and 87, 93, and 97 % for the MD value in early, moderate, and severe eyes, respectively. The agreement of the visual field defect area in CLOCK CHART(®) with the static fields was 85 and 100 % with Greve stages 0-I to I and II-VI, respectively, and 91, 96, and 96 % in early, moderate and severe glaucomatous eyes according to MD, respectively. The specificity of CLOCK CHART(®) was 89 %. CONCLUSION: CLOCK CHART(®) is a simple and reliable self-check screening chart for detecting visual field abnormalities in patients with glaucoma.