visual fields still matter - missouri optometric … g 32 (hfa 30-2 / 24-2) [email protected] visual...

Visual Fields Still MatterJohn Warren, OD

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Visual Fields Still Matter

Disclosure

While a founding partner of RevolutionEHR, I have no financial interest in the sale of any other techniques or technologies discussed during today’s presentations.

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A Bit Of VF History

Confrontations

Harrington Flox

Tangent Screen

Goldmann

Static Automated VF’s

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Sequential Analysis

Drawing of VF analysis as interpreted by examiner

Placing results of near point VF in patient record

Placing plotter results from Goldmann into patient record

Printing out individual field results

Printing out series of results with analysis

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Sequential Analysis

Evaluating series of VF’s in archived solution

Peritrend - Octopus

Dicon software

Oculus Easy Field software

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Trend Analysis

Peritrend

Statistical analysis

Visualization of fields in many displays

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Peritrend Example

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Trend Analysis

EyeSuite - Octopus 1-2-3, 300 and 900 series perimeters

Archives data

Performs trending

Displays statistical analysis

Displays graphical displays

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Eyesuite Example

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Glaucoma DiagnosisStructure

Function

Diagnosis

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Glaucoma Follow Up

Follow Up

Event Analysis

Trend Analysis

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Glaucoma Functional Analysis

One VF does not a diagnosis make

Must confirm defects

Initially

Events/Progression

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Event Analysis

Event Analysis

Change in VF

From “normal”

From one state of abnormal to another

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Glaucoma Progression Analysis

Detection of change with or without the presence of an event

More subtle changes

Subtle changes over time can result in events

Allows for earlier detection of damage

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Glaucoma Progression Analysis

Helps to filter noise from change

Subjective nature of VF’s makes them “noisy”

Trend analysis helps “smooth out” the change making its detection possible

Statistical analysis is MUCH MORE likely to detect progression

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•Diagnosis•Early recognition •Normal vs Abnormal•Decision to either start treating and/

or intensify follow up

•Single Field analysis•L/R / Pattern deviation•Change from Baseline

•Management•Diagnosed disease•Slow vs. Rapid•Decision to adapt treatment or

go for surgery

•Follow up•Trend analysis•Progression rate

Glaucoma diagnosis or Glaucoma management?

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Onset End stageProgression of the disease

MD 0

MD 30

Untreated Progression rate 0.2 - 2 dB/yr 1,2

1) Ophthalmology 2001;108:247-253, 2) Arch Ophthalmol. 2002 Oct;120(10):1268-79 EMGT.

Initial state

Impaired vision ?

100yrs20yrs

Life expectancy?

Course of the disease

Untreated progression rate is 0.2dB to 2dB per year

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Literature - Recommendations

Chauhan et al, Br J Ophthalmol 2008;92:569–573.

• 2 initial visual field examinations followed by regular tests every 6 months should allow to detect rapid (2dB/year) progression after 2 years

• In follow up, apply the same program and strategy

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What is Disability?

•US Definition for legal blindness: III4e isopter with <20° ∅• This corresponds with a Humphrey mean deviation of -22dB• This corresponds with an Octopus mean defect of 22dB

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Disability - Conclusions

• Consider complete vision loss to correspond with MD 22dB• Impaired vision quality can start earlier – depending on the distribution of

defects in the visual field.

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Common (Evidence) BaseGuidelines for rate of progression analysis

• Looking at global indices, we may want to see at what age the MD reaches 22dB, knowing that depending on the distribution of visual field defects, visual impairment may start already long before

• Decide on a suitable examination pattern and strategy, then perform 6 examinations within the first 2 years and follow up with examinations every 6 months.

• For the ability and thus quality of life (QOL) of a patient the binocular vision is to be considered and thus should be estimated as well to understand the patients situation and perspectives

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Progression rate in GlaucomaWhat are suitable test patterns for Glaucoma follow up?

•17 / 59 (29%) of TL in 10°•MD stronger reflects macular sensitivity

•12 / 74 (16%) of TL in 10°•MD stronger reflects peripheral sensitivity

Octopus G 32 (HFA 30-2 / 24-2)

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Progression rate in GlaucomaWhich strategy to choose? Patient acceptance vs. amount of information

Dynamic Strategy(SITA Standard)

TOP Strategy(SITA Fast)

•5-8 minutes•Higher resolution

•2-3 minutes•Lower resolution

-2

-4

+2 dB

+3 dB-6

-1

Average between last “SEEN” &

last “NOT SEEN”

30 dB

0

“SEEN” spots pull the field Up

“NOT SEEN” spots pull the field Down

Averaging of neighbouring test

locations

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RecommendationsWhat program and strategy to use

• Whenever possible apply the G-pattern or a similar pattern for Glaucoma follow up

• Choose a strategy with short duration and good repeatability (I recommend either the Dynamic or the TOP strategy, usually the TOP)

• Statsitically, the TOP strategy requires 25% more frequent visual field tests for the same significance, but test time is reduced to 50% compared to the Dynamic strategy and retest variability is smaller in TOP.)

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We have 6 tests – what now

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DescriptionCombined graph showing change in dB/year and significance for trend and for fluctuation

Global Trend

Worsening at the 5% 1% significance level

Improvement at the 5% 1% significance

Fluctuation at the 5% 1% significance level

Calculating yearly progression rate in dB/year and significance thereof

Scale Grey: Normality

15dB: Seriously impaired vision 25dB: Considered legally blind

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Progression rate in GlaucomaWhat time window to look at

• Time series over 5 years• Actual trend exceeds all time trend by 100%

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Progression rate in GlaucomaWhat time window to

look at

• Time series over 15 years• Actual trend is approx. reflected but trend line does not reflect the change

over time

80yrs, OAG both eyes, therapy since 1980

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look at

• Time series over 10 years• Actual trend exceeds all time trend by 100%

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look at

• Long term trends may under- or overestimate progression• An optimum between significance and actuality of trend is given at 5-6

examinations• Exception: Calculate trend over more tests if progression rate is small (<

approx. 0.5dB / year)

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Visual Fields Still Matter Progression rate in Glaucoma

Do trends extrapolate?

MD ≈ 3dB MD ≈ 7dB

Progression rate in

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Progression rate in Glaucoma



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MD ≈ 2.5dB MD ≈ 5dB


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Extrapolation of regressionAll examinations versus the most

recent ones

• Extrapolation of progression may over- or underestimate future developments

• The purpose of treatment is to reduce the progression

Rowe, Barbara, 08/23/1926

OCTOPUS 1-2-3

OD / 05/11/1998 / 15:30:45Greyscale (CO)

OS / 05/11/1998 / 15:33:49Greyscale (CO)

Classification: Comment: Pupil [mm]: IOP [mmHg]:Refraction S/C/A: -4// VA:Catch trials: 0/4(+), 0/4(-) RF: 0.0Parameters: 31.4 III 100 ms Duration: 02:14Programs: G Standard / White/White TOP Questions / Repetitions: 73 / 3

95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 22.8MD [< 2.0 dB]: 3.5sLV [< 2.5 dB]: 3.1

Classification: Comment: Pupil [mm]: IOP [mmHg]:Refraction S/C/A: // VA:Catch trials: 0/4(+), 0/4(-) RF: 0.0Parameters: 31.4 III 100 ms Duration: 02:12Programs: G Standard / White/White TOP Questions / Repetitions: 72 / 0

95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 26.4MD [< 2.0 dB]: -0.1sLV [< 2.5 dB]: 1.6

2.53.7

4.4 3.5

-0.60.5

0.9 -1.0


OCTOPUS 1-2-3

OD / 05/11/1998 / 15:30:45Corrected cluster analysis

OS / 05/11/1998 / 15:33:49Corrected cluster analysis

Classification: Comment: Pupil [mm]: IOP [mmHg]:Refraction S/C/A: -4// VA:Catch trials: 0/4(+), 0/4(-) RF: 0.0Parameters: 31.4 III 100 ms Duration: 02:14Programs: G Standard / White/White TOP Questions / Repetitions: 73 / 3

30°

MS [dB]: 22.8MD [< 2.0 dB]: 3.5sLV [< 2.5 dB]: 3.1

Classification: Comment: Pupil [mm]: IOP [mmHg]:Refraction S/C/A: // VA:Catch trials: 0/4(+), 0/4(-) RF: 0.0Parameters: 31.4 III 100 ms Duration: 02:12Programs: G Standard / White/White TOP Questions / Repetitions: 72 / 0

30°

MS [dB]: 26.4MD [< 2.0 dB]: -0.1sLV [< 2.5 dB]: 1.6

+

+

2.7

+

+

+

3.4

++

3.6

+

+

2.7

+

+

+

3.4

++

3.6

+

+

+

+

+

+

+

++

3.5

+

+

+

+

+

+

+

++

3.5

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Case Example05/11/1998


OCTOPUS 1-2-3

OD / 06/21/2000 / 09:53:27Greyscale (CO)

OS / 06/21/2000 / 09:49:46Greyscale (CO)

Classification: Comment: Pupil [mm]: 5. IOP [mmHg]:Refraction S/C/A: -4.00// VA:Catch trials: 0/3(+), 1/4(-) RF: 14.2Parameters: 31.4 III 100 ms Duration: 02:15Programs: G Standard / White/White TOP Questions / Repetitions: 71 / 1

95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 22.7MD [< 2.0 dB]: 3.5sLV [< 2.5 dB]: 3.3


95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 26.1MD [< 2.0 dB]: 0.0sLV [< 2.5 dB]: 2.0

2.91.7

6.4 2.9

-0.7-0.2

0.7 -0.1


OCTOPUS 1-2-3




30°

MS [dB]: 22.7MD [< 2.0 dB]: 3.5sLV [< 2.5 dB]: 3.3


30°

MS [dB]: 26.1MD [< 2.0 dB]: 0.0sLV [< 2.5 dB]: 2.0

+

+

+

+

+

+

2.3

7.02.6

+

+

+

+

+

+

+

2.3

7.02.6

+

+

+

+

+

2.4

2.4

+

+1.5

+

+

+

+

+

2.4

2.4

+

+1.5

+

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OCTOPUS 1-2-3

OD / 11/22/2002 / 10:53:49Greyscale (CO)

OS / 11/22/2002 / 10:58:42Greyscale (CO)

Classification: Comment: Pupil [mm]: 7. IOP [mmHg]:Refraction S/C/A: -4// VA:Catch trials: 0/3(+), 0/4(-) RF: 0.0Parameters: 31.4 III 100 ms Duration: 02:05Programs: G Standard / White/White TOP Questions / Repetitions: 70 / 0

95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 21.4MD [< 2.0 dB]: 4.6sLV [< 2.5 dB]: 5.8


95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 25.4MD [< 2.0 dB]: 0.6sLV [< 2.5 dB]: 1.9

2.50.7

11.4 3.2

0.01.8

0.2 0.4


OCTOPUS 1-2-3




30°

MS [dB]: 21.4MD [< 2.0 dB]: 4.6sLV [< 2.5 dB]: 5.8


30°

MS [dB]: 25.4MD [< 2.0 dB]: 0.6sLV [< 2.5 dB]: 1.9

+

+

+

+

1.6

+

6.8

8.07.0

2.3

+

+

+

+

1.6

+

6.8

8.07.0

2.3

4.2

+

+

+

+

+

+

++

+

4.2

+

+

+

+

+

+

++

+

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OCTOPUS 1-2-3

OD / 12/05/2003 / 09:52:44Greyscale (CO)

OS / 12/05/2003 / 09:49:13Greyscale (CO)


95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 20.2MD [< 2.0 dB]: 5.7sLV [< 2.5 dB]: 5.9


95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 22.4MD [< 2.0 dB]: 3.4sLV [< 2.5 dB]: 3.9

2.21.3

13.0 6.2

0.33.1

6.5 3.8


OCTOPUS 1-2-3




30°

MS [dB]: 20.2MD [< 2.0 dB]: 5.7sLV [< 2.5 dB]: 5.9


30°

MS [dB]: 22.4MD [< 2.0 dB]: 3.4sLV [< 2.5 dB]: 3.9

+

+

+

+

+

5.3

9.9

11.47.8

2.2

+

+

+

+

+

5.3

9.9

11.47.8

2.2

+

+

+

+

+

+

+

3.27.3

5.4

+

+

+

+

+

+

+

3.27.3

5.4

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OCTOPUS 1-2-3

OD / 11/02/2001 / 10:52:52Greyscale (CO)

OS / 11/02/2001 / 10:56:20Greyscale (CO)


95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 20.7MD [< 2.0 dB]: 5.4sLV [< 2.5 dB]: 5.1


95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 26.2MD [< 2.0 dB]: -0.1sLV [< 2.5 dB]: 1.9

2.00.8

11.8 7.0

-0.60.2

1.8 -1.7


OCTOPUS 1-2-3




30°

MS [dB]: 20.7MD [< 2.0 dB]: 5.4sLV [< 2.5 dB]: 5.1


30°

MS [dB]: 26.2MD [< 2.0 dB]: -0.1sLV [< 2.5 dB]: 1.9

+

+

+

+

+

3.6

6.5

10.17.6

9.6

+

+

+

+

+

3.6

6.5

10.17.6

9.6

+

+

+

+

+

+

+

++

5.1

+

+

+

+

+

+

+

++

5.1

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OCTOPUS 1-2-3



Classification: Comment: Pupil [mm]: IOP [mmHg]:Refraction S/C/A: -6.00// VA:Catch trials: 0/4(+), 0/4(-) RF: 0.0Parameters: 31.4 III 100 ms Duration: 02:15Programs: G Standard / White/White TOP Questions / Repetitions: 73 / 1

30°

MS [dB]: 18.5MD [< 2.0 dB]: 7.0sLV [< 2.5 dB]: 4.9


30°

MS [dB]: 22.0MD [< 2.0 dB]: 3.6sLV [< 2.5 dB]: 2.9

+

+

+

+

+

+

6.1

9.26.1

+

+

+

+

+

+

+

6.1

9.26.1

+

2.9

+

+

+

+

1.9

+

+4.6

4.0

2.9

+

+

+

+

1.9

+

+4.6

4.0


OCTOPUS 1-2-3

OD / 12/15/2008 / 14:47:41Greyscale (CO)

OS / 12/15/2008 / 14:52:00Greyscale (CO)


95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 18.5MD [< 2.0 dB]: 7.0sLV [< 2.5 dB]: 4.9


95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 22.0MD [< 2.0 dB]: 3.6sLV [< 2.5 dB]: 2.9

3.95.2

13.6 5.4

1.73.5

5.7 3.7

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Case Example

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Beyond Glaucoma

Other diseases that impact visual fields

ONH Drusen

Papilledema

Amiodorone Optic Atrophy

Large volume blood loss

Others

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Beyond GlaucomaOther diseases that impact visual fields

Optic Neuritis

AION

MS

Giant Cell Arteritis

Cranial Masses

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Amiodorone Optic Atrophy

Vision Wellness

Name: KEITH HEAPES

Patient ID: HEAPES_KEITHOS Session: 20080903_QUI_a

Date of Birth: Jan 29, 1949Examination Date: Sep 03, 2008

2D Thickness [µm] RNFL Deviation Probability Rim/Cup Area [mm]

Macula QA: 3 Disc QA: 3

Remarks Findings are: Thickness ONL* RNFL WNL* C/D=0.47 * WNL=Within Normal Limits Fundus Image should be evaluated separately. *ONL=Outside Normal Limits

Warren Eye Care

(262) 752-2020

www.warreneyecarecenter.com

Technology And Care You Trust

Name: ___________________

Signature: ________________

S100805DJ1-11.776-L Talia Technology Ltd. www.talia.com SW Ver.5.1 SP2B-IE7

Vision Wellness

Name: KEITH HEAPES

Patient ID: HEAPES_KEITHOD Session: 20080903_QUI_a

Date of Birth: Jan 29, 1949Examination Date: Sep 03, 2008



Remarks Findings are: Thickness WNL* RNFL WNL* C/D=0.45 * WNL=Within Normal Limits Fundus Image should be evaluated separately. *ONL=Outside Normal Limits

Warren Eye Care

(262) 752-2020



Name: ___________________

Signature: ________________


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Beyond Glaucoma

Other systemic Diagnoses

MS to set baseline and/or determine impact on VF

Post CVA for baseline and to detect any change

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MS

Vision Wellness

Name: Shenelle Waters

Patient ID: Waters_ShenelleOD Session: 20090410_QUI_a

Date of Birth: Jan 15, 1971Examination Date: Apr 10, 2009




Warren Eye Care

(262) 752-2020



Name: ___________________

Signature: ________________


Vision Wellness

Name: Shenelle Waters

Patient ID: Waters_ShenelleOS Session: 20090410_QUI_a

Date of Birth: Jan 15, 1971Examination Date: Apr 10, 2009




Warren Eye Care

(262) 752-2020



Name: ___________________

Signature: ________________


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Beyond Glaucoma

Symptoms that warrant visual field analysis

Headache w/out refractive cause

May still need to rule out other pathology

Unexplained reduction in BCVA

Salomone, Michael, 07/28/1957

OCTOPUS 1-2-3

OD / 12/03/2004 / 10:40:43Greyscale (CO)

OS / 12/03/2004 / 10:37:20Greyscale (CO)

Classification: Comment: Pupil [mm]: 6. IOP [mmHg]:Refraction S/C/A: // VA:Catch trials: 0/3(+), 0/4(-) RF: 0.0Parameters: 31.4 III 100 ms Duration: 02:06Programs: G Standard / White/White TOP Questions / Repetitions: 71 / 0

95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 22.6MD [< 2.0 dB]: 5.3sLV [< 2.5 dB]: 4.4


95%..100%

83%...94%

71%...82%

59%...70%

47%...58%

35%...46%

23%...34%

11%...22%

0%...10%

30°

MS [dB]: 26.5MD [< 2.0 dB]: 1.3sLV [< 2.5 dB]: 2.2

3.95.8

4.2 7.4

2.60.9

0.1 1.6


OCTOPUS 1-2-3

OD / 12/03/2004 / 10:40:43Defect curve

OS / 12/03/2004 / 10:37:20Defect curve


30°

MS [dB]: 22.6MD [< 2.0 dB]: 5.3sLV [< 2.5 dB]: 4.4


30°

MS [dB]: 26.5MD [< 2.0 dB]: 1.3sLV [< 2.5 dB]: 2.2

Diffuse defect [dB]: 3.1

1 59

5%

95%

-5

0

5

10

15

20

25

Diffuse defect [dB]: 1.3

1 59

5%

95%

-5

0

5

10

15

20

25


OCTOPUS 1-2-3




30°

MS [dB]: 22.6MD [< 2.0 dB]: 5.3sLV [< 2.5 dB]: 4.4


30°

MS [dB]: 26.5MD [< 2.0 dB]: 1.3sLV [< 2.5 dB]: 2.2

2.6

+

+

3.4

3.4

+

+

1.44.7

10.6

2.6

+

+

3.4

3.4

+

+

1.44.7

10.6

+

+

+

+

+

+

+

++

+

+

+

+

+

+

+

+

++

+

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Headache

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Questions?

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visual fields still matter - missouri optometric … g 32 (hfa 30-2 / 24-2) [email protected] visual...

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