Effect of decreased retinal illumination on frequency doubling technology

Perimetric Comparison Between the IMOvifa and Humphrey Field Analyzer

PRCIS

IMO visual function analyzer (IMOvifa), a binocular perimeter, has similar output to the Humphrey Field Analyzer (HFA), but reduced the measurement time.

PURPOSE

The purpose of this study is to evaluate the performance of IMOvifa, a perimeter that performs binocular visual field (VF) testing, and to compare its results with standard automated perimetry.

METHODS

All patients underwent HFA 24-2 SITA-Fast and IMOvifa 24-2 AIZE-Rapid on the same day. Mean deviation (MD), pattern SD (PSD), foveal threshold, and visual field index (VFI) were compared between the 2 perimeters using Wilcoxon signed-rank tests, Pearson correlation, and Bland-Altman plot. Measurement time for performing VF for both eyes was also collected for each device.

RESULTS

In this cross-sectional study, 138 eyes (including 25 healthy, 48 glaucoma suspects, and 65 primary open angle glaucoma) of 69 patients were evaluated. Measurement time was significantly faster for IMOvifa compared with HFA (256 vs. 419 s, P <0.001). No significant differences were seen in MD and VFI between HFA and IMOvifa (both P >0.05). Significant differences were seen in mean PSD 3.2 (2.7, 3.6) dB for HFA versus 4.1 (3.5, 4.6) for IMOvifa ( P <0.001), and foveal threshold 33.9 (33.1, 34.6) dB for HFA versus 30.6 (29.3, 31.9) dB for IMOvifa ( P <0.001). Pearson r was strong for MD ( r =0.90, P <0.001), PSD ( r =0.78, P <0.001), and VFI ( r =0.94, P <0.001). The mean difference (95% limits of agreement) was -0.1 (-3.8, 3.5) dB for MD, -0.4 (-3.4, 2.5) dB for PSD, and 0.1 (-8.9, 9.1) dB for VFI, respectively.

CONCLUSIONS

IMOvifa reduced measurement time by 39%. MD, PSD, and VFI values for IMOvifa showed good agreement with HFA SITA-Fast strategy. This perimeter reduced fatigue for both patient and examiner. Additional studies are needed to determine whether it will be useful for routine VF testing.

Comparison of head-mounted perimeter (imo®) and Humphrey Field Analyzer

Purpose

The head-mounted automated perimeter imo^® is a new portable perimeter that does not require a dark room and can be used to examine patients in any setting. In this study, imo 24plus (1-2) AIZE examinations were compared with previous Humphrey Field Analyzer (HFA) 30-2 (SITA standard) examinations within the same patient.

Patients and methods

imo examinations (either head-mounted [i-H] or fixed [i-F] type) were performed in patients with glaucoma or suspected glaucoma who had already experienced HFA five or more times. Measurement time and correlations of mean deviation (MD) and visual field index (VFI) values were compared between groups for HFA, i-H, i-F, and imo total (i-T). Fixation loss (FL), false-positive (FP), and false-negative (FN) detection rates were compared. The percentage of binocular random single-eye tests under possible non-occlusion conditions using imo was determined. Mann–Whitney U test was performed, and Spearman’s rank-order correlation coefficient was calculated.

Results

The inclusion period was July to December 2016. Among 273 subjects (543 eyes), 147 (292 eyes) were tested with i-H type and 126 (251 eyes) with i-F type. Mean MD values for HFA and i-T were -6.1±7.8 and -6.2±7.1 dB, respectively. Mean measurement times for HFA, i-H, i-F, and i-T were 15.23±2.07, 10.47±2.11, 11.04±2.31, and 10.54±2.19 minutes, respectively (P<0.01 for HFA vs i-H/i-F). Total mean measurement time was shorter by 30.8% for i-T vs HFA. Correlation coefficients of MD and VFI were R²>0.81 for HFA vs i-H and i-F. FP and FN detection rates were significantly higher with i-T than HFA; there was no significant difference in FL. Binocular random single-eye tests were possible in 85% of cases.

Conclusion

imo reduced measurement time by 30.8%. imo VFI and MD values were highly correlated with HFA. As i-F and i-H types produced similar results, imo can be used in accordance with the patient’s situation.

Visual Field Testing with Head-Mounted Perimeter 'imo'

PURPOSE

We developed a new portable head-mounted perimeter, "imo", which performs visual field (VF) testing under flexible conditions without a dark room. Besides the monocular eye test, imo can present a test target randomly to either eye without occlusion (a binocular random single eye test). The performance of imo was evaluated.

METHODS

Using full HD transmissive LCD and high intensity LED backlights, imo can display a test target under the same test conditions as the Humphrey Field Analyzer (HFA). The monocular and binocular random single eye tests by imo and the HFA test were performed on 40 eyes of 20 subjects with glaucoma. VF sensitivity results by the monocular and binocular random single eye tests were compared, and these test results were further compared to those by the HFA. The subjects were asked whether they noticed which eye was being tested during the test.

RESULTS

The mean sensitivity (MS) obtained with the HFA highly correlated with the MS by the imo monocular test (R: r = 0.96, L: r = 0.94, P < 0.001) and the binocular random single eye test (R: r = 0.97, L: r = 0.98, P < 0.001). The MS values by the monocular and binocular random single eye tests also highly correlated (R: r = 0.96, L: r = 0.95, P < 0.001). No subject could detect which eye was being tested during the examination.

CONCLUSIONS

The perimeter imo can obtain VF sensitivity highly compatible to that by the standard automated perimeter. The binocular random single eye test provides a non-occlusion test condition without the examinee being aware of the tested eye.

Choice of Stimulus Range and Size Can Reduce Test-Retest Variability in Glaucomatous Visual Field Defects

PURPOSE

To develop guidelines for engineering perimetric stimuli to reduce test-retest variability in glaucomatous defects.

METHODS

Perimetric testing was performed on one eye for 62 patients with glaucoma and 41 age-similar controls on size III and frequency-doubling perimetry and three custom tests with Gaussian blob and Gabor sinusoid stimuli. Stimulus range was controlled by values for ceiling (maximum sensitivity) and floor (minimum sensitivity). Bland-Altman analysis was used to derive 95% limits of agreement on test and retest, and bootstrap analysis was used to test the hypotheses about peak variability.

RESULTS

Limits of agreement for the three custom stimuli were similar in width (0.72 to 0.79 log units) and peak variability (0.22 to 0.29 log units) for a stimulus range of 1.7 log units. The width of the limits of agreement for size III decreased from 1.78 to 1.37 to 0.99 log units for stimulus ranges of 3.9, 2.7, and 1.7 log units, respectively (F = 3.23, P < 0.001); peak variability was 0.99, 0.54, and 0.34 log units, respectively (P < 0.01). For a stimulus range of 1.3 log units, limits of agreement were narrowest with Gabor and widest with size III stimuli, and peak variability was lower (P < 0.01) with Gabor (0.18 log units) and frequency-doubling perimetry (0.24 log units) than with size III stimuli (0.38 log units).

CONCLUSIONS

Test-retest variability in glaucomatous visual field defects was substantially reduced by engineering the stimuli.

TRANSLATIONAL RELEVANCE

The guidelines should allow developers to choose from a wide range of stimuli.

Assessing spatial and temporal properties of perimetric stimuli for resistance to clinical variations in retinal illumination

PURPOSE

To develop perimetric stimuli for which sensitivities are more resistant to reduced retinal illumination than current clinical perimeters.

METHODS

Fifty-four people free of eye disease were dilated and tested monocularly. For each test, retinal illumination was attenuated with neutral density (ND) filters, and a standard adaptation model was fit to derive mean and SEM for the adaptation parameter (NDhalf). For different stimuli, t-tests on NDhalf were used to assess significance of differences in consistency with Weber's law. Three experiments used custom Gaussian-windowed contrast sensitivity perimetry (CSP). Experiment 1 used CSP-1, with a Gaussian temporal pulse, a spatial frequency of 0.375 cyc/deg (cpd), and SD of 1.5°. Experiment 1 also used the Humphrey Matrix perimeter, with the N-30 test using 0.25 cpd and 25 Hz flicker. Experiment 2 used a rectangular temporal pulse, SDs of 0.25° and 0.5°, and spatial frequencies of 0.0 and 1.0 cpd. Experiment 3 used CSP-2, with 5-Hz flicker, SDs from 0.5° to 1.8°, and spatial frequencies from 0.14 to 0.50 cpd.

RESULTS

In Experiment 1, CSP-1 was more consistent with Weber's law (NDhalf ± SEM = 1.86 ± 0.08 log unit) than N-30 (NDhalf = 1.03 ± 0.03 log unit; t > 9, P < 0.0001). All stimuli used in Experiments 2 and 3 had comparable consistency with Weber's law (NDhalf = 1.49-1.69 log unit; t < 2).

CONCLUSIONS

Perimetric sensitivities were consistent with Weber's law when higher temporal frequencies were avoided.

Oxygenation state and mesopic sensitivity to dynamic contrast stimuli

PURPOSE

Comparative studies suggest that increasing photoreceptor oxygen consumption in dim light, relative to bright light, may make the outer retina susceptible to hypoxia at light levels relevant to aviation at night. Accordingly, this study investigates effects of relevant oxygenation states on sensitivity to a dynamic contrast stimulus at low photopic and mesopic light levels experienced during night flying.

METHODS

Threshold sensitivity to frequency-doubled contrast stimuli was assessed under mild hypoxia (breathing 14.1% oxygen), hyperoxia (100% oxygen), and normoxia (air) using frequency doubling perimetry, viewing at background fields of approximately 10 cd/m2 and approximately 1 cd/m2. Data were analyzed by retinal eccentricity and visual field quadrant.

RESULTS

At low photopic luminance (approximately 10 cd/m2), sensitivity was marginally enhanced when breathing 100% oxygen. At mesopic luminance (approximately 1 cd/m2), sensitivity was consistently poorest with hypoxia and greatest with supplementary oxygen at all eccentricities and in all field quadrants, suggesting oxygen-dependent performance.

CONCLUSIONS

The known effects of oxygenation state on pupil size are likely to influence frequency doubling perimetry thresholds, but oxygen-dependent changes in mesopic sensitivity are greater than expected from altered retinal illumination alone and support outer retinal (photoreceptor) susceptibility to hypoxia under twilight viewing.

Glaucoma Detection With Frequency Doubling Perimetry and Short-wavelength Perimetry

PURPOSE

The aim of this analysis was to evaluate the diagnostic usefulness of frequency doubling technology (FDT) perimetry and short-wavelength perimetry (SWAP). Moreover, to study a combination of both methods using the machine-learning technique double-bagging, which was recently established in glaucoma research.

METHODS

Forty-three patients with "preperimetric" open-angle glaucoma (glaucomatous optic disc atrophy and no visual field defect in standard perimetry), 26 patients with "perimetric" open angle glaucoma (glaucomatous optic disc atrophy and visual field defect in standard perimetry), and 40 control subjects had FDT screening (protocol: C-20-5) and SWAP (Octopus 101, G2). Criteria for exclusion were color vision abnormalities, media opacities, and an age below 31 years or above 63 years. Data of 1 eye of each patient and control subject entered the statistical evaluation. A point wise evaluation of the diagnostic power of SWAP values was performed to derive spatial patterns of visual field loss. A double-bagging machine-learning algorithm was used to train classification rules on the basis of a combination of FDT scores and nerve fiber related visual field losses in SWAP. The diagnostic power of the classifiers was compared regarding their misclassification error rates and area under the receiver-operating characteristic curve.

RESULTS

The combination of FDT perimetry and SWAP yielded better diagnostic results compared with FDT or SWAP separately. The overall estimated misclassification error rate of the combined classifier was 24% compared with 28% for both SWAP and FDT perimetry. Regarding the estimated performance of classifier at high specificities (>80%) in control eyes as measured by the partial area under the receiver-operating characteristic curve, the combination of both instruments is also superior to the individual instruments.

CONCLUSIONS

A combination of SWAP and FDT perimetry, each targeting different neuronal pathways, may improve early glaucoma detection.

Prediction of future scotoma on conventional automated static perimetry using frequency doubling technology perimetry

AIM

To see if scotoma detected with frequency doubling technology (FDT) is confirmed by Humphrey field analyser (HFA) 3 years later.

METHODS

Subjects were first examined with the screening C-20-1 program of FDT. The visual field was examined annually for 4 years using HFA program C30-2. The central 58 test points in HFA were assigned to one of the 17 clusters corresponding to FDT test points. Each cluster was represented as the lowest probability symbol of total deviation (TD) of the HFA test points included in the cluster. Clusters were graded normal, suspected scotoma, and scotoma depending on probability of TD-5% or more, 5%-1%, less than 1%, respectively. Relative risk (RR) of abnormality on FDT for future scotoma on HFA was estimated.

RESULTS

80 eyes of 42 patients were followed up for 4 years. While 4.0% of normal clusters of HFA with normal FDT results developed into scotoma cluster, 20.8% of normal clusters with abnormal FDT results developed into scotoma cluster with HFA at the third year. RR for future scotoma was 5.24 (95% CI, 2.75 to 10.0, p<0.05).

CONCLUSION

An abnormal result in FDT shows a high risk of future scotoma on HFA after 3 years even if the original HFA perimetry showed normal results.

The effects of interocular differences in retinal illuminance on vision and binocularity

BACKGROUND

It is known that binocular function is affected by interocular differences in retinal image size, shape, clarity, and illumination. The present study was performed to systematically examine the effects of interocular differences in retinal illuminance on monocular visual acuity, fusion, and stereopsis.

METHODS

Fifty adults with normal binocularity and a best-corrected visual acuity of 20/20 or better were enrolled. We examined best-corrected visual acuity, fusion, and stereoacuity as monocular retinal illuminance was gradually reduced by increasing neutral density filters from 0.2 neutral density (ND; 63% transmission) to 3.0 ND (0.1% transmission) in increments of 0.2 ND. We measured the smallest size of fusion slide by major amblyoscope, and evaluated stereoacuity with the Titmus test and the Lang test.

RESULTS

The best-corrected visual acuity began to decrease significantly when the value of the neutral density filter reached 2.0 ND (1% transmission; p<0.01). The level of fusion decreased significantly when monocular retinal illuminance was reduced to 2.0 ND (p<0.01). Stereoacuity began to decline significantly when the value of the neutral density filter was 1.4 ND (4% transmission) with the Titmus test and 1.6 ND (2.5% transmission) with the Lang test.

CONCLUSIONS

A binocularly conducted Titmus test was the most sensitive to the presence of monocularly induced retinal illuminance deterioration.

Standard measures of visual acuity do not predict drivers' recognition performance under day or night conditions

PURPOSE

This study investigated whether visual acuity or contrast sensitivity, measured under a range of luminance conditions, could predict drivers' recognition performance under real-world day and night road conditions.

METHODS

Twenty-four participants, comprising three age groups (younger, mean = 21.5 years; middle-aged, mean = 46.6 years; and older, mean = 71.9 years), drove around a 1.8-km closed road circuit under day and nighttime conditions. At night, headlight intensity was varied over 1.5 log-units by ND filters mounted on the headlights. Participants drove around the circuit under five light conditions (daytime and four at night) and were asked to report relevant targets, including road signs, large low-contrast road obstacles, and pedestrians who wore retroreflective markings on either the torso or the limb joints (creating "biological motion"). Real-world recognition performance was measured as percent correct recognition and, in the case of low-contrast road obstacles, avoided. Clinical vision tests included high-contrast visual acuity and Pelli-Robson letter contrast sensitivity measured at four luminance levels.

RESULTS

Real-world recognition performance of all age groups was significantly degraded under low light conditions, and this impairment was greater for the older participants. These changes in drivers' recognition performance were more strongly predicted by contrast sensitivity than visual acuity measured under standard photopic conditions. Interestingly, contrast sensitivity was highly correlated with visual acuity measured under low-luminance conditions. Further analyses showed that recognition performance while driving is better predicted by combinations of two tests: either 1) photopic visual acuity and photopic contrast sensitivity, or 2) photopic and mesopic visual acuity.

CONCLUSIONS

These findings confirm that visibility is seriously degraded during night driving and that the problem is greater for older drivers. These changes in real-world recognition performance were better predicted by a standard test of contrast sensitivity than by visual acuity. Still better predictions can be obtained by the use of two vision tests. The implications of these findings for driver licensing standards are discussed.

Characteristics of the normative database for the Humphrey matrix perimeter

PURPOSE

The Humphrey Matrix (Carl Zeiss Meditec, Dublin CA; Welch-Allyn, Skaneateles, NY) is a high-spatial-resolution perimeter that uses frequency-doubling stimuli. It incorporates an efficient test strategy that assumes that age, eccentricity, and test procedure type have only small effects on sensitivity. The results used to create the normative database for the perimeter were examined, to see whether these assumptions were met and to examine the form of the normative data.

METHOD

Visual fields were measured (Matrix 30-2, 24-2, 10-2 and Macula patterns) in >275 subjects judged to be normal by a battery of clinical procedures. The right eye was always tested first.

RESULTS

Sensitivity decreased by approximately 0.7 dB per age decade across all eccentricities; sensitivity decreased with eccentricity, typically by <5 dB at the most peripheral points tested. Although there was no systematic difference in sensitivity between the 30-2 and 24-2 tests, the Macula test sensitivities were typically 1 dB higher than for the 10-2 test. Sensitivity in the left eye was slightly lower than in the right, with the difference being significantly greater in the temporal visual field. In most test locations, the 95% confidence interval of normal sensitivity was approximately 6 dB below the median sensitivity.

CONCLUSIONS

The performance of the test strategy in the Matrix perimeter is appropriately matched to the response characteristics of the normal population. The finding of a spatially nonuniform difference in sensitivity between left and right eyes is attributable to light-adaptation differences between the eyes. This effect is accounted for in the perimeter's normative database.

Agreement between frequency doubling perimetry and static perimetry in eyes with high tension glaucoma and normal tension glaucoma

AIMS

To investigate the agreement in results between frequency doubling technology (FDT) and the conventional automated static perimeter in eyes with normal tension glaucoma (NTG) and high tension glaucoma (HTG).

METHODS

72 eyes of 36 patients, who had two or more experiences with the Humphrey field analyser (HFA) program C30-2, were examined with the screening C-20-1 program of FDT. The result of FDT at each of the 17 stimulus points was graded as one of four categories. 58 out of 76 test points of HFA were assigned to one of the 17 clusters corresponding to FDT test points. Each cluster was represented as the lowest (scotoma of HFA) or the highest (threshold of HFA) probability symbol of total deviation (TD) of the HFA test points included in the cluster. The agreement between scotoma/threshold of HFA and FDT results was evaluated for NTG and HTG.

RESULTS

In a total of 65 eyes, the Spearman coefficients between the FDT and HFA (threshold/scotoma of HFA) were 0.599 and 0.515 (p<0.0001), respectively. In the HFA mean deviation matched 20 HTG eyes and 20 NTG eyes, the number of points with abnormal FDT results were 102 and 62 in eyes with HTG and NTG, respectively. The eyes with HTG had more abnormal FDT results than NTG eyes (p=0.0014, Mann-Whitney U test). The kappa coefficient between FDT and threshold of HFA in eyes with HTG and NTG was 0.288 and 0.520, respectively, and the agreement between FDT and scotoma of HFA was 0.480 and 0.439, respectively.

CONCLUSIONS

The best agreement of the results of FDT and HFA was observed in eyes with NTG using threshold of HFA. The eyes with HTG showed lower agreement with more abnormal points in FDT results, which suggests enough sensitivity of FDT in eyes with NTG, and higher sensitivity of FDT in eyes with HTG.

Combined use of frequency doubling perimetry and polarimetric measurements of retinal nerve fiber layer in glaucoma detection

PURPOSE

The aim of this study was to evaluate the diagnostic usefulness of the combined use of frequency-doubling technology (FDT) perimetry and polarimetry of the retinal nerve fiber layer.

DESIGN

Cross-sectional study.

METHODS

Seventy ocular hypertensive patients (normal optic disk and standard perimetry, elevated intraocular pressure [>21 mm Hg]), 59 patients with "preperimetric" open-angle glaucoma (glaucomatous optic disk atrophy, elevated intraocular pressure [>21 mm Hg], no visual field defect in standard perimetry), 105 patients with "perimetric" open-angle glaucoma (glaucomatous optic disk atrophy and clearly marked visual field defect), and 73 control subjects had FDT screening (protocol: C-20-5) and polarimetric measurements (GDx). Criteria for exclusion: optic disks larger than 4 mm(2), media opacities, patients younger than 33 years or older than 66 years. None of the subjects had earlier FDT perimetry. One eye of each patient and control subject entered the statistical evaluation. Database and statistical software were used for case-wise recalculation of all missed localized probability levels to create a FDT screening score.

RESULTS

At a predefined specificity of 94.5% in control eyes, discrimination between "perimetric" glaucoma and normal subjects is superior using the FDT perimetry (sensitivity = 84.8%) in comparison to polarimetry (sensitivity = 63.8%), whereas sensitivity is similar with both methods in "preperimetric" patients (GDx, FDT: 25.4%). In several cases, patients classified as glaucomatous by the GDx are not the same patients as identified by the FDT perimetry. Therefore, a two-dimensional discrimination analysis can increase correct positive classification. Using a linear combination of the present FDT screening score and polarimetry ("the number"), 92.4% of "perimetric" glaucoma eyes and 44.1% of "preperimetric" glaucoma eyes have been classified as glaucomatous.

CONCLUSION

Joint usage of polarimetry and FDT perimetry indicate that a combination of different techniques which can uncover different glaucoma properties, might be helpful in early glaucoma detection.

Effect of dichoptic adaptation on frequency-doubling perimetry

BACKGROUND

In frequency-doubling technology (FDT) perimetry, the second eye tested has reduced sensitivity. We investigated the cause of this sensitivity reduction.

METHODS

Contrast sensitivity was measured for frequency doubling (0.25 cpd, 25 Hz) and nonflickering (4 cpd) gratings, arranged similarly to the targets in the FDT perimeter (Welch Allyn, Skaneateles Falls, NY, and Humphrey Instruments, San Leandro, CA). Various test orders were examined.

RESULTS

Frequency-doubling (FD) sensitivity was reduced (0.15 log) in the second eye. A similar reduction occurred when first and second eye gratings were oriented orthogonally, suggesting that dichoptic contrast adaptation was not the cause. FD sensitivity was little affected after testing with nonflickering gratings, suggesting that fatigue effects were small. Sensitivity was reduced when testing was performed after 5 min of opaque occlusion. The use of a translucent occluder eliminated the reduction in sensitivity in the second eye.

CONCLUSION

We confirm the presence of reduced sensitivity in the second eye tested with FD perimetry and find that it is caused by delayed light adaptation post-occlusion.