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[Reduction of retinal light sensitivity in diabetic patients].

BACKGROUND: Visual field loss in diabetic patients has received comparatively little attention. The aim of the present study was firstly to assess the influence of type 2 diabetes mellitus on retinal light sensitivity in diabetic patients without signs of diabetic retinopathy (DR) and secondly to assess the association between visual field loss and the severity of nonproliferative DR. PATIENTS AND METHODS: 151 eyes of 151 diabetic patients with type 2 diabetes mellitus and 30 eyes of 30 healthy volunteers were included in our study. Visual acuity was 0.7 or better with correction. DR staging was based on a modified Airlie-House classification. The eyes were divided into four groups: no DR, mild NPDR, moderate NPDR and severe NPDR. Ophthalmic examination was normal in all diabetic patients, except for DR. All participants underwent visual field testing with the C 30-2 program of the Humphrey field analyser. RESULTS: Retinal light sensitivity was significantly reduced before clinically detectable DR with MD (mean deviation) p values less than 10% in 14.3% (8 of 56 eyes). Patients with mild NPDR had a significant reduction of retinal sensitivity in 21.1% (8 of 38 eyes), with moderate NPDR in 45.8% (11 of 24 eyes) and with severe NPDR in 63.6% (21 of 33 eyes). PSD (pattern standard deviation) p values less than 10% were observed in 7.1% (4 of 56 eyes) in patients without DR, with mild DR in 31.6% (12 of 38 eyes), with moderate in 50% (12 of 24 eyes) and in patients with severe DR in 60.1% (20 of 33 eyes). Using the analytical STATPAC program of the Humphrey Field Analyzer, the reduction of retinal sensitivity was significant between controls and diabetic patients without DR and between individual groups of diabetic patients. CONCLUSIONS: The severity of visual field loss was greater in advanced stages of DR. In diabetic patients with severe DR, a significant reduction of retinal light sensitivity was observed in more than 60%. In diabetic patients without DR, despite no evident capillary closure on fluorescein angiography--similar as in the control group, where retinal sensitivity was normal in all cases--a significant reduction of retinal sensitivity was found in more than 14.3%.

Adult↗

Computerized visual field screening in the management of patients with ocular hypertension.

Visual field testing which the Computer fully automatic computerized perimeter (Heijl & Krakau 1975) employing a supra-liminal screening test procedure was used in a material of 1013 eyes with ocular hypertension in which earlier routine perimetry (kinetic and static) on the Goldmann perimeter had yielded a normal result. The automatic screening was repeated if positive, and manual control perimetry was used in order to confirm or reject identified field defects. This procedure revealed field defects that could be confirmed at both automatic and manual perimetry in 3.6% of the eyes. In the control group the incidence of field defects found at manual perimetry during the same time interval was calculated at 0.4%. Thus automatic screening revealed several times more field defects than manual routine perimetry. Eyes in which repeated automatic screening had indicated defects which manual control perimetry failed to confirm, showed a high percentage of field loss at later follow-up. The results are discussed, and the conclusion is drawn that automatic screening is clearly superior to manual routine perimetry used at present. The most practical solution in many eye departments would be to use a computerized perimeter for the visual field screening of glaucoma suspects.

Adult↗

Comparing significance and magnitude of glaucomatous visual field defects using the SITA and Full Threshold strategies.

PURPOSE: To evaluate and compare visual field test results as presented by the Statpac interpretation tools in tests obtained with the new short SITA Standard and the even shorter SITA Fast strategies to the traditional Humphrey Full Threshold strategy. SUBJECTS AND METHODS: One eye of each of 44 glaucoma patients was examined four times with each of the Humphrey SITA Standard, SITA Fast, and Full Threshold strategies. Another 21 eyes of 21 normal subjects had one eye examined once with each of the three strategies. RESULTS: Average light sensitivity was highest with the shortest SITA Fast strategy and lowest with the longest Full Threshold strategy. Magnitude of field loss as defined by the Statpac Mean Deviation (MD) did not differ between the three strategies. In the glaucoma patients, both SITA strategies showed larger number of significantly depressed points in Statpac probability maps than the Full Threshold strategy. In the normal subjects SITA Standard showed more significantly depressed points, close to the statistically expected number, at the lowest probability level (p<5%) than both Full Threshold and SITA Fast. At higher probability levels (p<1%) SITA Standard and Full Threshold showed similar numbers of significantly depressed points. CONCLUSION: Both SITA Standard and SITA Fast identified at least as much significant glaucomatous field loss as the Full Threshold using the Statpac interpretation tools.

Adult↗

Quality of vision with presbyopic contact lens correction: subjective and light sensitivity rating.

PURPOSE: To quantify the quality of vision achieved with multifocal and bifocal contact lenses. METHODS: We analyzed differential light sensitivity by computerized automatic perimetry in 21 patients wearing monofocal soft contact lenses (group 1, controls) and multifocal and bifocal contact lenses (groups 2 and 3, respectively). Seven patients each were fitted with multifocal or bifocal contact lenses; seven patients were without contact lenses (without correction for testing the visual periphery and with near-vision correction using monofocal contact lens for testing the central 30 degrees of vision). The type of correction was randomly changed in a crossover fashion so that each eye was examined at different times with different corrections. Humphrey 640 VFA computerized automated perimetry was used to test visual fields at baseline, 45 days, and 3, 4.5, and 6 months. RESULTS: A statistically significant difference was found between the global sensitivities (GS) of the central visual field in patients with near-vision monofocal contact lenses and with bifocal contact lenses (P=0.0273) and between the GS of the central visual fields with multifocal contact lenses and with bifocal contact lenses (P=0.0261). In both cases, the GS were significantly reduced with bifocal contact lenses (total GS: group 1, 11256 dB (Decibels); group 2, 11154 dB; group 3, 10679 dB). CONCLUSIONS: The results indicate that there is reduced differential light sensitivity in the central 30 deg of the visual field with bifocal contact lenses compared with multifocal contact lenses and monofocal contact lenses (controls).

Contact Lenses, Hydrophilic↗

Influence of the luminance level on visual performance with a disposable soft cosmetic tinted contact lens.

The purpose of the present work was to study the effect on visual performance of wearing disposable soft tinted contact lenses for cosmetic purposes. Parameters such as contrast sensitivity (Vistech 6000), colour vision (Farnsworth-Munsell 100-Hue colour test), visual fields (static Goldmann perimetry) and subjective vision (what the wearer feels while wearing the lenses) were studied under different illumination levels in order to check for possible vision losses while wearing these contact lenses at low illumination levels. Sixteen emmetropic subjects were fitted consecutively with seven pairs of different colour lenses (Optima Colors lenses by Bausch & Lomb), and the experimental parameters were measured under four different illumination levels (60, 6, 1, and 0.1 cd/m2; but 15 and 0.3 cd/m2 for the static perimetry) The results obtained showed no statistically significant differences in visual performance between wearing the lenses and not wearing them (p > 0.01), except for the static perimetry, in which statistically significant differences (p < 0.01) occur at eccentricities greater than 30 degrees.

Adolescent↗

Macular coloboma in siblings affected by different phenotypes of retinitis pigmentosa.

Purpose To report the clinical association between macular coloboma (early-onset macular dystrophies/atrophic changes) and different phenotypes of retinitis pigmentosa (RP). Methods Three young-adult siblings, two males and one female, were retrospectively studied. These patients underwent two complete ophthalmologic examinations (27-month follow-up), including orthoptic evaluation, colour vision test, visual field, corneal topography, electronystagmography, fluorescein angiography, and electroretinography. Eye check, automated visual field test, and complete electroretinographic study were also conducted on other asymptomatic members of the same family. Results All symptomatic siblings were affected by manifest congenital nystagmus, poor visual acuity, and progressive visual field impairment in both eyes, bilaterally presenting macular coloboma associated with three different RP patterns: classic RP; mild dystrophy of the retinal pigment epithelium, associated with subnormal electroretinographic findings (subclinical form of RP); and sector RP. The ophthalmologic reports regarding their deceased father documented that he had suffered from the same alterations of ocular movements and visual performances diagnosing, in both eyes, extensive atrophic changes of the macular area completely surrounded by pigmented bone spicules (RP-type tapeto-retinal dystrophy). The other investigated relatives did not show any specific and/or significant ocular disorder. Conclusions In these three adult members of the same family, the concomitance between macular coloboma and different intrafamilial RP phenotypes is described. This association represents an autosomal dominant clinical entity, hitherto observed only in non familial sporadic cases.Eye (2004) 18, 421-428. doi:10.1038/sj.eye.6700689

Adult↗

A confrontation test of visual fields in the low-vision patient.

We report a simple method for measuring the extent of the visual field in patients from whom this measurement is difficult. One Maddox rod is used before the eye under test. Through the Maddox rod lens, this eye sees a white streak produced by a penlight. While fixating this white streak another penlight is brought into the field of view from the periphery. The patient is required to report only whether he sees one or two light streaks. The results correlate well with field measurements made on the tangent screen in patients with simulated field losses.

Humans↗

Automated suprathreshold screening for glaucoma: the Baltimore Eye Survey.

PURPOSE: To evaluate automated suprathreshold perimetric screening for glaucoma in a population-based survey of ocular disorders in east Baltimore, Maryland. METHODS: A population-based sample of persons > or = 40 years of age residing in 16 clusters was selected for an ocular screening examination that included automated suprathreshold testing with the Full Field 120 program of the Humphrey Field Analyzer. Subjects who failed the test underwent manual testing to confirm the defect. Subjects were referred for definitive examination by an ophthalmologist if they had an abnormal field, visual acuity worse than 20/30, intraocular pressure > 21 mm Hg, optic disc damage, a history of glaucoma, or shallow angles. The sensitivity and specificity of the automated visual field testing for identifying glaucoma was estimated and compared with other methods to screen for glaucoma. RESULTS: Of 5,341 subjects > or = 40 years of age who underwent a screening eye examination at neighborhood centers, 4,735 (89%) completed the automated field test. The median test time was 7.25 minutes per eye. Screening test results were abnormal in one or both eyes in 1,234 (26%) of the subjects. Kinetic perimetry was performed on 95% of these subjects, and defects were confirmed for 448 (36%) of them. Hence, 9.5% of the 4,735 subjects who completed the automated test were referred for definitive examination because the defect on automated perimetry was confirmed on manual testing. For a specificity of 90%, the sensitivity of the screening visual field test to detect glaucoma was 52% for 17 or more relative or absolute defects, higher than that of intraocular pressure at 39% for a cut-off of 20.5 mm Hg, vertical cup-to-disc ratio at 45% for a cut-off of 0.53, narrowest remaining rim width at 42% for a cut-off of 0.16, and was comparable to a combination of these and other nonfield parameters. CONCLUSION: Suprathreshold testing performed better than nonperimetry-based screening tests for glaucoma. However, a number of logistical weaknesses of this visual field screening method were identified.

Adult↗

Clinical application of mfERG/VEP in assessing superior altitudinal hemifield loss.

Multifocal ERG (mfERG) and multifocal VEP (mfVEP) have been used widely in the investigation of pathological changes or functional variations in the visual system. Altitudinal hemifield loss is a visual field defect that is usually found in patients with ischaemic optic neuropathy (ION). Anterior ischaemic optic neuropathy (AION) is a complex multi-factorial disease and it is difficult to diagnose according to clinical symptoms and signs alone. AION is believed to be caused by an infarction of the optic nerve due to the occlusion of the posterior ciliary arteries. The current report presents a patient diagnosed with non-arteritic AION. In this report, the mfERG findings did not match the results of the visual field test but those of the mfVEP did. After consideration of the visual electrophysiological and visual field results, the defect arises from neither the retina nor the visual pathway behind the optic chiasma. Hence, the optic nerve is the most likely location of the lesion, causing the superior altitudinal hemi-field loss. This report shows that the mfERG and mfVEP techniques can be used for objective visual field assessment to supplement the conventional visual field testing.

Electroretinography↗

Causes of blindness and visual impairment in a population of older Americans: The Salisbury Eye Evaluation Study.

OBJECTIVE: To determine the causes of blindness and visual impairment in a population-based sample of older Americans. METHODS: A random sample of 3821 residents of Salisbury, Md, between the ages of 65 and 84 years was identified from Medicare records. Sixty-six percent (2520 persons) agreed to undergo an eye examination; 26% of the participants were African American. The clinical examination included acuity testing with an Early Treatment Diabetic Retinopathy Study chart and standardized refraction testing for those with a visual acuity worse than 20/30, slitlamp and dilated retinal examination by an ophthalmologist, tonometry, lens and fundus photography, and a suprathreshold visual field test. Visual impairment was defined as a best-corrected acuity in the better-seeing eye worse than 20/40 and better than 20/200, while blindness was acuity in the better-seeing eye of 20/200 or worse. For those with a visual acuity worse than 20/40 in either eye, one or more causes were assigned by an ophthalmologist and a final cause for each eye was confirmed by a panel of 3 subspecialty ophthalmologists (O.D.S., H.A.Q., and S.B.B.) based on all available evidence. RESULTS: Bilateral presenting acuity worse than 20/40 increased from 4% in the 65- to 74-year age group to 16% in the 80- to 84-year age group. One third of those with presenting acuity worse than 20/40 improved to 20/40 or better with refraction. Overall, 4.5% had a best-corrected acuity worse than 20/40. African Americans were more likely to remain visually impaired than were whites despite refraction (odds ratio [95% confidence interval], 1.7 [1.1-2.6]). Whites were most often impaired or blind from age-related macular degeneration (1.2% vs 0.5%; P=.09). African Americans had higher rates of impairment and blindness from cataract or posterior capsular opacification (2.7% vs 1.1%; P=.006), glaucoma (0.9% vs 0.1%; P=.006), and diabetic retinopathy (1.2% vs 0.2%; P=. 004). CONCLUSIONS: More than half of those with visual impairment or blindness had conditions that were either surgically treatable or potentially preventable. African Americans had a disproportionate number of blinding diseases, particularly those amenable to eye care intervention. Targeted interventions for specific populations to increase appropriate eye care use would greatly improve vision and function in older Americans. Arch Ophthalmol. 2000;118:819-825

Aged↗

Glaucoma Hemifield Test. Automated visual field evaluation.

We have developed an algorithm, the Glaucoma Hemifield Test (GHT), for automated evaluation of single static threshold visual field test results in glaucoma. The GHT uses empirically determined limits of normality for up-down differences in the Statpac probability maps of the Humphrey Field Analyzer to detect localized visual field loss. It is also constructed to detect field loss that is symmetric around the horizontal meridian. Analysis is done in five corresponding pairs of sectors that are based on the normal anatomy of the retinal nerve fiber layer. Deviations from the age-corrected normal threshold in the most sensitive portions of the visual field are used to detect general reductions of sensitivity or abnormally high sensitivities. The GHT provides brief visual field evaluations printed on the field chart as plain text. The aim of this article is to describe the fundamentals of the analysis program and to provide clinical examples.

Adult↗

Disc excavation in dominant optic atrophy: differentiation from normal tension glaucoma.

OBJECTIVE: In patients with dominant optic atrophy (DOA, Kjer type), excavation of the optic nerve develops, and these patients may be misdiagnosed as having normal tension glaucoma (NTG). This study examined disc morphologic features in patients with DOA and explored features that help distinguish this condition from NTG. DESIGN: Noncomparative, observational case series. PARTICIPANTS: Patients with DOA who were seen at the Duke University Eye Center between 1987 and 1996 and who had bilateral optic nerve photographs. METHODS: Retrospective chart review of the results of visual acuity testing, visual field testing by Goldmann perimetry, color vision testing, intraocular pressure measurement, and observation of bilateral optic nerve photographs. MAIN OUTCOME MEASURES: Appearance of the optic disc and peripapillary zone in patients with DOA. RESULTS: Nine patients were identified. The mean age at the time of evaluation was 28 years (range, 11-62 years). Most patients had a mild to moderate reduction in visual acuity. Color vision as tested with Hardy-Rand-Rittler plates was reduced (4.0/10 +/- 4.2/10). A cup-to-disc ratio of more than 0.5 was observed in at least one eye of eight patients. A temporal wedge-shaped area of excavation was observed in 14 of the 18 eyes studied. Moderate to severe temporal pallor was observed in all of the eyes. Pallor of the remaining (noncupped) neuroretinal rim was also observed consistently, ranging from mild to moderate. A gray crescent and some degree of peripapillary atrophy were noted in all eyes. CONCLUSIONS: Several clinical features, including early age of onset, preferential loss of central vision, sparing of the peripheral fields, pallor of the remaining neuroretinal rim, and a family history of unexplained visual loss or optic atrophy, help to distinguish patients with DOA from those with NTG.

Adolescent↗

Multifocal visual evoked potential in nonorganic visual field loss.

OBJECTIVE: To evaluate the use of multifocal visual evoked potentials in the diagnosis of nonorganic visual field loss. METHODS: Five patients with unexplained visual field loss underwent full neuro-ophthalmic examination, Humphrey visual field testing, and multifocal visual evoked potential testing using the Accumap objective perimeter (ObjectiVision Pty Ltd, Sydney, Australia). RESULTS: In all 5 cases, the results of the ophthalmic examination did not correlate with the degree of visual field loss seen on Humphrey visual field testing. Multifocal visual evoked potentials testing showed essentially normal tracings. CONCLUSIONS: Multifocal visual evoked potentials may be useful in cases of difficult to prove functional visual field loss or in cases in which objective documentation of normal function is needed.

Adolescent↗

Retinal toxicity in long term hydroxychloroquine treatment.

OBJECTIVE: To report clinical experience from patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) who were receiving recommended doses of hydroxychloroquine for more than six years, and were monitored for evidence of hydroxychloroquine related retinopathy every six months. METHODS: A prospective (and continuing) evaluation was made of the potential retinal toxicity of hydroxychloroquine in a cohort of 360 Greek patients followed for RA and SLE, 58 of whom have received long term treatment ( > six years). Fundoscopy, colour vision tests, dark adaptation tests, visual field testing, automated perimetry, and electroretinogram were performed every six months. RESULTS: Among 58 patients receiving hydroxychloroquine for more than six years, two relatively young women (3.5%), one treated for RA and the other treated for SLE, developed characteristic hydroxychloroquine related toxic retinal lesions after cumulative doses of 700 g (6.5 years) and 730 g (8 years) of hydroxychloroquine, respectively. Bilateral visual acuity was 6/6 and 6/7.5, respectively; both patients had normal colour perception. Despite an early diagnosis and cessation of treatment, permanent visual field paracentral scotomata in both patients, and persisting lesions in fluorescein angiography in the patient with SLE, were observed at 4.5 and 3 years of follow up, respectively. No other specific cases of hydroxychloroquine related retinopathy have to date been identified in the remaining 302 patients. CONCLUSION: Cases of irreversible, hydroxychloroquine related retinopathy in patients who did not receive overdoses have not been reported previously. The present observations in two relatively young patients should raise our concern regarding the long term usage of an increasingly popular medication in rheumatology practice.

Adult↗

Effect of eye testing order on automated perimetry results using the Swedish Interactive Threshold Algorithm standard 24-2.

OBJECTIVE: To evaluate whether the order of eye testing affects the mean deviation (MD) or the test reliability of visual field testing using the Swedish Interactive Threshold Algorithm (SITA) standard 24-2. METHODS: Consecutive patients with manifest or suspect glaucoma with 2 prior sets of SITA standard 24-2 test results performed on the right eye first were enrolled. A subsequent test was performed on the left eye first. For each eye, the MD and the test reliability indexes (> or = 20%) were compared among the 3 successive examinations. RESULTS: Forty-seven patients (29 women and 18 men; mean +/- SD age, 70.6 +/- 11.9 years) were enrolled. The MD +/- SD was -5.83 +/- 5.43 dB OD and -5.46 +/- 4.86 dB OS. There was no statistically significant difference in the MD or the test reliability among the 3 test results for either eye. Fixation loss was responsible for the unreliable fields in almost all cases. CONCLUSIONS: Among this cohort of patients experienced with automated perimetry in a glaucoma subspecialty practice, changing the order of eye testing using the SITA standard 24-2 did not have a significant effect on the MD or the test reliability. Intereye fatigue may not be clinically significant with this algorithm. Fixation loss remains a problem with the use of this algorithm.

Aged↗

Improving the sensitivity of the OKP visual field screening test with the use of neutral density filters.

Oculokinetic perimetry (OKP) has been developed to screen for glaucomatous field loss but has relatively poor sensitivity when compared with threshold perimetry. Forty-two eyes from 42 patients with glaucomatous field loss on Humphrey threshold perimetry and 32 normals performed hand-held OKP under controlled conditions of refraction and lighting. Those who passed the standard test had their OKP cutoff determined with increasing neutral density filters (NDFs) at a new point 15 degrees from fixation in the inferotemporal field (where first glaucomatous defects are rarest). OKP was then repeated with a NDF that increased the ambient light by 0.3 log units from cut off. Of the 16 glaucomatous eyes to pass standard OKP, 9 failed the NDF test, improving the sensitivity from 62% to 83% (p < 0.05). These 9 eyes had field defects that were significantly less severe (mean defect 4.85 vs 7.91 (p < 0.05) and corrected pattern standard deviation 4.12 vs 7.00 (p < 0.05) and were from younger patients (mean age 56 vs 66 years; p < 0.05) than those who failed standard OKP. None of the 32 normals failed standard OKP and only 1 of 32 failed the NDF test. The use of NDFs to customise OKP, producing essentially a staged suprathreshold contrast sensitivity test, appears to increase the sensitivity of the OKP screener without degrading its specificity, particularly in younger subjects.

Aged↗

Bilateral optic nerve atrophy in myotonic dystrophy.

PURPOSE: To document a case of bilateral optic atrophy in a patient with myotonic dystrophy. Myotonic dystrophy is an autosomal dominant disorder, genetically resulting from an expansion of an unstable CTG repeat in the 3'-untranslated region of a protein kinase gene (DMPK) on chromosome 19q13.3. METHODS: Case report, clinical examination, fundus photographs, visual fields, visual evoked potentials, electroretinograms, and genetic studies of a 56-year-old woman clinically diagnosed with myotonic dystrophy. RESULTS: The patient experienced decreased vision consisting of light perception with the right eye and 20/25 with the left. Fundus examination showed bilateral pallor of the optic disks. Intraocular pressure was normal. Visual field testing, visual evoked potentials, and electroretinogram were abnormal. A pathologic CTG expansion in the myotonic dystrophy gene was found. CONCLUSIONS: In a patient with myotonic dystrophy, confirmed with genetic molecular diagnosis, bilateral optic atrophy was present. Optic atrophy should be considered a possible complication of myotonic dystrophy.

3' Untranslated Regions↗

Prospective analysis of diplopia after anterior temporal lobectomy for mesial temporal lobe sclerosis.

OBJECT: In this prospective study the authors investigated the incidence and natural history of postoperative diplopia in patients undergoing anterior temporal lobectomy (ATL) and amygdalohippocampectomy for medically intractable mesial temporal lobe epilepsy. METHODS: Forty-seven patients scheduled for ATL for medically refractory seizures were examined preoperatively, 2 to 7 days postoperatively, and 3 to 6 months postoperatively. Ophthalmological examination including pupillary measurements, stereoacuity measurements, palpebral fissure measurements, vertical fusional amplitudes, Lancaster red green testing, visual field testing, and alternate cover testing was performed. Antiepileptic drug levels were monitored. Nine (19%) of 47 patients developed diplopia postoperatively. The diplopia was caused by trochlear nerve palsy in every case. No oculomotor nerve dysfunction was documented. Trochlear nerve function recovered completely in all patients within 3 to 6 months postoperatively. CONCLUSIONS: Postoperative diplopia following ATL occurs more often than previously thought and is primarily due to trochlear nerve dysfunction. Awareness of this transient complication is important in preoperative patient counseling.

Adolescent↗