C. Springer

Use of fundus perimetry (microperimetry) to quantify macular sensitivity

The advances in retinal imaging technologies have led to enormous innovation towards diagnostic in current ophthalmology, enabling the practitioner to detect early retinal changes and to document treatment effects. While, in the past, retinoscopy, visual acuity testing and perimetry played the major role in functional diagnostics, today, laser-based systems like laser scanning imaging systems especially for fluorescein-angiography, optical coherence tomography, electrodiagnostic systems and the analysis of retinal vessels may be used as well. However, the challenge to correlate subjective alterations or clinical changes with visual function, still remains. Micro- or fundus perimetry offers the option to test retinal sensitivity while directly observing the fundus. In this paper, we review the literature encompassing the results of more than 25 years of fundus perimetry, i.e. perimetry under simultaneous visualization of the fundus. During this time, results on known diseases and reproducibility of the technique were published, but a lot of work was also performed on the combination of different examination methods, allowing a synopsis of long-term results and new approaches by combining different methods and improving each of them. The first part of this review attends to improvements of the method. The second part addresses the clinical and diagnostic values. The final part is dedicated to diagnostic and long-term observation of fundus perimetric results beginning with common and rare diseases like age-related macular degeneration, macular holes and diabetic retinopathy, various types of macular dystrophies ending with challenges in conventional perimetry like glaucoma and malingering. Due to the experience and progress in the field of fundus perimetry and retinal imaging, the method has long passed its role of observing and has all the potential for prediction, early detection and treatment-monitoring of macular diseases.

Interferon versus Methotrexate in Intermediate Uveitis With Macular Edema: Results of a Randomized Controlled Clinical Trial

PURPOSE To compare interferon (IFN) beta with methotrexate (MTX) in the treatment of intermediate uveitis with macular edema. DESIGN Monocentric, prospective, randomized, controlled clinical trial. METHODS SETTING Specialized uveitis center at the University of Heidelberg. PATIENT OR STUDY POPULATION: Patients with either primary intermediate uveitis or uveitis associated with multiple sclerosis. MAIN INCLUSION CRITERIA: Visual acuity of 20/30 or worse (0.2 logarithm of the minimal angle of resolution) and macular edema of more than 250 μm (central 1-mm in optical coherence tomography; Stratus). Randomization into either IFN beta 44 μg subcutaneously 3 times weekly or 20 mg MTX subcutaneously once weekly. MAIN OUTCOME MEASURES At 3 months, the primary outcome parameter of mean change in visual acuity was evaluated and efficacy was determined. Secondary parameters were macular edema by optical coherence tomography, inflammatory activity, and retinal sensitivity by microperimetry (MP-1; Nidek). In case of treatment failure, switching to the other treatment arm was possible. RESULTS Nineteen patients were included. Ten were randomized to MTX, and 9 were randomized to IFN beta. At 3 months, visual acuity improved a mean 0.31 logarithm of the minimal angle of resolution (range, -0.02 to -0.96, 15.6 letters on the Early Treatment Diabetic Retinopathy Study chart) in the IFN beta group versus a mean 0.09 logarithm of the minimal angle of resolution (range, 0.12 to -0.38, 4.7 letters) in the MTX arm (P = .0435, Mann-Whitney U test). Macular thickness decreased by a mean of 206 μm (range, -41 to -416 μm) in the IFN arm, but increased by 47 μm (range, 108 to -28 μm) in the MTX group (P < .0001). CONCLUSIONS Although the sample size is small, results of the trial support superiority of IFN beta over MTX in the treatment of macular edema in the setting of intermediate uveitis.

Adult α-mannosidosis Clinical progression in the absence of demyelination

α-Mannosidosis is an inherited lysosomal storage disease. The authors report three siblings (ages 38 to 47 years) with the rare adult variant. All three had late-onset ataxia and retinal degeneration, adding to hearing loss, cognitive impairment, and dysotosis multiplex. One sibling also had psychosis. MRI revealed cerebellar atrophy and predominantly parieto-occipital white matter changes. MR spectroscopy showed no evidence for demyelination. It appears that the disabling course of adult α-mannosidosis is caused by lysosomal accumulation rather than demyelination.&agr;-Mannosidosis is an inherited lysosomal storage disease. The authors report three siblings (ages 38 to 47 years) with the rare adult variant. All three had late-onset ataxia and retinal degeneration, adding to hearing loss, cognitive impairment, and dysotosis multiplex. One sibling also had psychosis. MRI revealed cerebellar atrophy and predominantly parieto-occipital white matter changes. MR spectroscopy showed no evidence for demyelination. It appears that the disabling course of adult &agr;-mannosidosis is caused by lysosomal accumulation rather than demyelination.

Objektivierung der Sehfunktionen bei Begutachtungen

ZusammenfassungZur Prüfung des Sehvermögens ist eine möglichst objektive Bestimmung der Sehfunktion anzustreben. Ophthalmologische Basisuntersuchungen wie Visusprüfung und Perimetrie sind jedoch von den Angaben des Patienten abhängig. Sofern der Untersuchte keine geeigneten subjektiven Angaben machen kann, wie dies für Kleinkinder oder geistig Behinderte zutrifft, aber auch bei Zweifeln an der Richtigkeit der Angaben und gar dem Verdacht auf Simulation oder Aggravation, ist bei der Beurteilung der Sehleistung grundsätzlich die angegebene Funktion mit verschiedenen Untersuchungsmethoden auf ihre Richtigkeit zu überprüfen und der Befund objektiver Prüfverfahren wie der elektrophysiologischen Zusatzdiagnostik zusammen mit dem morphologischen Befund zu berücksichtigen.AbstractFor the determination of visual function an objective assessment is essential. Basic ophthalmologic examinations such as measurement of visual acuity and perimetry are dependent on patient statements. If the patient is not being able to provide adequate answers, as is the case for small children or mentally retarded patients, or also if the accuracy of the patient’s statements is doubtful or simulation or aggravation is suspected, the denoted function in the evaluation of visual acuity has to be checked on consistency using different examination methods, and the results of objective functional tests, such as electrophysiology and morphological features, have to be taken into account.

Determination of visual function in legal assessment

ZusammenfassungZur Prüfung des Sehvermögens ist eine möglichst objektive Bestimmung der Sehfunktion anzustreben. Ophthalmologische Basisuntersuchungen wie Visusprüfung und Perimetrie sind jedoch von den Angaben des Patienten abhängig. Sofern der Untersuchte keine geeigneten subjektiven Angaben machen kann, wie dies für Kleinkinder oder geistig Behinderte zutrifft, aber auch bei Zweifeln an der Richtigkeit der Angaben und gar dem Verdacht auf Simulation oder Aggravation, ist bei der Beurteilung der Sehleistung grundsätzlich die angegebene Funktion mit verschiedenen Untersuchungsmethoden auf ihre Richtigkeit zu überprüfen und der Befund objektiver Prüfverfahren wie der elektrophysiologischen Zusatzdiagnostik zusammen mit dem morphologischen Befund zu berücksichtigen.AbstractFor the determination of visual function an objective assessment is essential. Basic ophthalmologic examinations such as measurement of visual acuity and perimetry are dependent on patient statements. If the patient is not being able to provide adequate answers, as is the case for small children or mentally retarded patients, or also if the accuracy of the patient’s statements is doubtful or simulation or aggravation is suspected, the denoted function in the evaluation of visual acuity has to be checked on consistency using different examination methods, and the results of objective functional tests, such as electrophysiology and morphological features, have to be taken into account.

Visual functions in phenylketonuria-evaluating the dopamine and long-chain polyunsaturated fatty acids depletion hypotheses.

BACKGROUND In phenylketonuria presymptomatic treatment following newborn screening prevents severe mental and physical impairment. The reasons for subtle impairments of cerebral functions despite early treatment remain unclear. We assessed a broad spectrum of visual functions in early-treated patients with phenylketonuria and evaluated two hypotheses-the dopamine and the long-chain polyunsaturated fatty acids (LCPUFAs) depletion hypotheses. METHODS Contrast sensitivity, colour vision, electroretinography, frequency doubling technology campimetry (FDT), and their relation with blood phenylalanine and docosahexaenoic acid levels were assessed in 36 patients with phenylketonuria and 18 age-matched healthy controls. RESULTS Contrast sensitivity was significantly lower and total error scores in colour vision significantly higher in patients than controls. Electroretinography results differed significantly between patients and controls. We found a trend for the effect of phenylalanine-levels on contrast sensitivity and a significant effect on colour vision/FDT results. Docosahexaenoic acid levels in erythrocytes were not associated with visual functions. CONCLUSION This is the first evaluation of visual functions in phenylketonuria using a comprehensive ophthalmological test battery. We found no evidence supporting the long-chain polyunsaturated fatty acids depletion hypothesis. However, the effect of phenylalanine-levels on visual functions suggests that imbalance between phenylalanine and tyrosine may affect retinal dopamine levels in phenylketonuria. This is supported by the similar patterns of visual functions in patients with phenylketonuria observed in our study and patients with Parkinsons disease.

Fundus perimetry in functional diagnostics of glaucoma. Applicable in the practice

Examination of the visual field using static automated perimetry (SAP) is the method of choice for the detection of functional damage secondary to glaucoma. However, with SAP early visual field defects might be missed even if there is already visible damage of the retinal nerve fibre. The microperimetry or beter fundus perimetry provides a detailed examination of the differential luminance threshold within defined retinal areas. However, in contrast to lesions of the retinal receptors, in cases of glaucomatous damage the retinal fibre course has to be considered resulting in a displacement between the structural lesion and the location of the related functional defect. The functional damage may be detected at earlier stages and with enhanced spatial resolution compared to conventional SAP. The extra costs and time associated with the application of fundus perimetry have prevented its widespread use. Current developments are leading to new options.ZusammenfassungDie Gesichtsfelduntersuchung mittels statischer automatischer Perimetrie (SAP) ist die Methode der Wahl zur Funktionsbestimmung beim Glaukom. Dennoch lassen sich damit beginnende Skotome oft nicht darstellen, selbst wenn es bereits zu morphologisch erkennbaren Schäden der Nervenfaserschicht gekommen ist. Dies gilt insbesondere für Nervenfaserbündeldefekte. Die Mikroperimetrie oder Fundusperimetrie erlaubt eine gezielte Untersuchung der Lichtunterschiedsempfindlichkeit über spezifischen, zugehörigen Netzhautarealen. Beim Glaukomschaden muss im Gegensatz zur primären Schädigung der Rezeptoren der Verlauf der Nervenfasern und die dadurch hervorgerufene Lokalisation des hervorgerufenen Funktionsausfalls berücksichtigt werden. Dabei ist der Nachweis einer Funktionsschädigung möglicherweise frühzeitiger als mit der konventionellen statischen Schwellenperimetrie möglich. Der zusätzliche Aufwand an Kosten und Zeit hat die Verbreitung der Fundusperimetrie bisher eingeschränkt. Aktuelle Entwicklungen könnten neue Perspektiven bieten.AbstractExamination of the visual field using static automated perimetry (SAP) is the method of choice for the detection of functional damage secondary to glaucoma. However, with SAP early visual field defects might be missed even if there is already visible damage of the retinal nerve fibre. The microperimetry or beter fundus perimetry provides a detailed examination of the differential luminance threshold within defined retinal areas. However, in contrast to lesions of the retinal receptors, in cases of glaucomatous damage the retinal fibre course has to be considered resulting in a displacement between the structural lesion and the location of the related functional defect. The functional damage may be detected at earlier stages and with enhanced spatial resolution compared to conventional SAP. The extra costs and time associated with the application of fundus perimetry have prevented its widespread use. Current developments are leading to new options.

Fundusperimetrie in der Glaukomdiagnostik

Examination of the visual field using static automated perimetry (SAP) is the method of choice for the detection of functional damage secondary to glaucoma. However, with SAP early visual field defects might be missed even if there is already visible damage of the retinal nerve fibre. The microperimetry or beter fundus perimetry provides a detailed examination of the differential luminance threshold within defined retinal areas. However, in contrast to lesions of the retinal receptors, in cases of glaucomatous damage the retinal fibre course has to be considered resulting in a displacement between the structural lesion and the location of the related functional defect. The functional damage may be detected at earlier stages and with enhanced spatial resolution compared to conventional SAP. The extra costs and time associated with the application of fundus perimetry have prevented its widespread use. Current developments are leading to new options.ZusammenfassungDie Gesichtsfelduntersuchung mittels statischer automatischer Perimetrie (SAP) ist die Methode der Wahl zur Funktionsbestimmung beim Glaukom. Dennoch lassen sich damit beginnende Skotome oft nicht darstellen, selbst wenn es bereits zu morphologisch erkennbaren Schäden der Nervenfaserschicht gekommen ist. Dies gilt insbesondere für Nervenfaserbündeldefekte. Die Mikroperimetrie oder Fundusperimetrie erlaubt eine gezielte Untersuchung der Lichtunterschiedsempfindlichkeit über spezifischen, zugehörigen Netzhautarealen. Beim Glaukomschaden muss im Gegensatz zur primären Schädigung der Rezeptoren der Verlauf der Nervenfasern und die dadurch hervorgerufene Lokalisation des hervorgerufenen Funktionsausfalls berücksichtigt werden. Dabei ist der Nachweis einer Funktionsschädigung möglicherweise frühzeitiger als mit der konventionellen statischen Schwellenperimetrie möglich. Der zusätzliche Aufwand an Kosten und Zeit hat die Verbreitung der Fundusperimetrie bisher eingeschränkt. Aktuelle Entwicklungen könnten neue Perspektiven bieten.AbstractExamination of the visual field using static automated perimetry (SAP) is the method of choice for the detection of functional damage secondary to glaucoma. However, with SAP early visual field defects might be missed even if there is already visible damage of the retinal nerve fibre. The microperimetry or beter fundus perimetry provides a detailed examination of the differential luminance threshold within defined retinal areas. However, in contrast to lesions of the retinal receptors, in cases of glaucomatous damage the retinal fibre course has to be considered resulting in a displacement between the structural lesion and the location of the related functional defect. The functional damage may be detected at earlier stages and with enhanced spatial resolution compared to conventional SAP. The extra costs and time associated with the application of fundus perimetry have prevented its widespread use. Current developments are leading to new options.

Fundusperimetrie in der Glaukomdiagnostik@@@Fundus perimetry in functional diagnostics of glaucoma: Schon praktisch anwendbar?@@@Applicable in the practice?

Examination of the visual field using static automated perimetry (SAP) is the method of choice for the detection of functional damage secondary to glaucoma. However, with SAP early visual field defects might be missed even if there is already visible damage of the retinal nerve fibre. The microperimetry or beter fundus perimetry provides a detailed examination of the differential luminance threshold within defined retinal areas. However, in contrast to lesions of the retinal receptors, in cases of glaucomatous damage the retinal fibre course has to be considered resulting in a displacement between the structural lesion and the location of the related functional defect. The functional damage may be detected at earlier stages and with enhanced spatial resolution compared to conventional SAP. The extra costs and time associated with the application of fundus perimetry have prevented its widespread use. Current developments are leading to new options.ZusammenfassungDie Gesichtsfelduntersuchung mittels statischer automatischer Perimetrie (SAP) ist die Methode der Wahl zur Funktionsbestimmung beim Glaukom. Dennoch lassen sich damit beginnende Skotome oft nicht darstellen, selbst wenn es bereits zu morphologisch erkennbaren Schäden der Nervenfaserschicht gekommen ist. Dies gilt insbesondere für Nervenfaserbündeldefekte. Die Mikroperimetrie oder Fundusperimetrie erlaubt eine gezielte Untersuchung der Lichtunterschiedsempfindlichkeit über spezifischen, zugehörigen Netzhautarealen. Beim Glaukomschaden muss im Gegensatz zur primären Schädigung der Rezeptoren der Verlauf der Nervenfasern und die dadurch hervorgerufene Lokalisation des hervorgerufenen Funktionsausfalls berücksichtigt werden. Dabei ist der Nachweis einer Funktionsschädigung möglicherweise frühzeitiger als mit der konventionellen statischen Schwellenperimetrie möglich. Der zusätzliche Aufwand an Kosten und Zeit hat die Verbreitung der Fundusperimetrie bisher eingeschränkt. Aktuelle Entwicklungen könnten neue Perspektiven bieten.AbstractExamination of the visual field using static automated perimetry (SAP) is the method of choice for the detection of functional damage secondary to glaucoma. However, with SAP early visual field defects might be missed even if there is already visible damage of the retinal nerve fibre. The microperimetry or beter fundus perimetry provides a detailed examination of the differential luminance threshold within defined retinal areas. However, in contrast to lesions of the retinal receptors, in cases of glaucomatous damage the retinal fibre course has to be considered resulting in a displacement between the structural lesion and the location of the related functional defect. The functional damage may be detected at earlier stages and with enhanced spatial resolution compared to conventional SAP. The extra costs and time associated with the application of fundus perimetry have prevented its widespread use. Current developments are leading to new options.