Reclaim the periphery!

New approaches to old issues

Lars Frisn
Institute of Neuroscience and Physiology/Ophthalmology Gteborg University, Sweden

CAP

Kinetic

Terra incognita

By definition, contractions proceed centripetally. Periphery test is required for early diagnosis.

Generally, it seems reasonable to expect that any progressive disorder that ends up in a central field remnant should involve some contraction and/or peripheral depression at an early stage

Progressive concentric depression & contraction.

Periphery test may aid early diagnosis.

Concentric visual field contractions

- Tapetoretinal degenerations - Optic nerve hypoplasia - Glaucoma - Chronic papilledema - Drusen of the nerve head - Perioptic neuropathy - Vigabatrin toxicity - Somatoform (functional, - Fictitious - Fatigue - Idiopathic hysterical )

Examples of localized contractions

- Anterior V1: loss of temporal crescent

Diagnosis requires periphery test

- lateral geniculate body

Retinotopy is less clear for the pathways - good peripheral tests may well be useful

- optic nerve hypoplasia

Frisn & Holmegaard: Spectrum of optic nerve hypoplasia. Br J Ophthalmol. 1978; 62:7-15.

Conditions of recent interest

- epilepsy surgery -> 50 (-100) % VFD - vigabatrin toxicity -> ~ 50 (-100) % VFD

Meyer s loop
Adolph Meyer The connections of the occipital lobes and the present status of the cerebral visual affections Trans Ass Am Physicians 22: 716, 1907

Centennial jubilee coming up!

Klingler & Ludwig: Atlas Cerebri Humani. Karger, 1956

Technique: teasing freeze-thawed tissue

Williams, Gluhbegovic & Jew: The Human Brain. Harper & Row, 1980

Falconer & Wilson 1958

Van Buren & Baldwin 1958

Barton et al. Brain 128: 2123, 2005

Magnetic resonance tractography

Nilsson, Starck, Ljungberg, Rydenhag & Frisn: Tractography of the optic radiation after temporal lobe resection (in prep)

Vigabatrin (Sabril, Sabrilex) - partial epilepsy - pediatric epilepsy viGABAtrin (gamma-amino-butyric acid) transferase inhibitor Vigabatrin is toxic to retinal ganglion cells and/or their axons

Concentric contraction & peripheral depression - central field remains largely normal

C-shaped pattern of RNFL atrophy

Frisn & Malmgren: Characterization of vigabatrin-associated optic atrophy. Acta Ophthalmol Scand 81: 466, 2003

Inclusion of peripheral field data should help illuminate relationships to optic disk and nerve fiber layer parameters

~ 1/3 of RNFL axons belong to retinal ganglion cells located outside 30

Periphery is important

How to access the periphery ? What determines the periphery ?

Outer limits with and without extra-polar fixation marks and retraction of eyelids:

25%
For concentric contractions/depressions: focus on the nasal & temporal periphery

Outer limit only is generally inefficient Aim to assess border zone, i e, slope

15 LCD screen at 0.25 m distance can access 60 - 120 of horizontal eccentricity

LCD/CRT-based perimeters
DLS (several authors) High-pass Resolution, Ring (Frisn) Motion (Wall) Rarebit (Frisn) <- Free software <- Free software

Component (Fahle) Internet-based (several)

Rarebit micro dot 0.5 x MAR

HRP, normal eye, right temporal periphery

Motion perimetry, right nasal periphery (courtesy of Younger & Wall)

Ocular hypertension Normal

Rarebit test principles

- use stimuli of minimal subtense (ideally smaller than receptive fields), - at high & fixed contrast (easy to see) - exposed briefly (to negate sweep gains),

- check once only for the presence of

function (no thresholding),

- in ever-new, non-overlapping locations;

- calculate Hit Rate =
sum seen sum shown

Rarebit perimetry, right temporal periphery

Normal eyes

Subtle compression of the chiasm

Rarebit perimetry, right nasal periphery

3 subjects treated with vigabatrin, ordered by cumulative dose.

Rarebit perimetry, ctd

Frisn L: Vigabatrin-associated loss of vision: rarebit perimetry illuminates dose-damage relationship. Acta Ophthalmol Scand 82: 54, 2004

Blum RG, Gates LK, Jamed BR How important are peripheral fields? Arch Ophthalmol 61: 1 8, 1959 - 3078 eyes - Arc perimeter: 2 mm white target - Tangent screen: 1 mm white target at 1 m - 72 (seventy-two!!) examiners

Reclaim the periphery!

The end