84 Lynn

Investigative Ophthalmology
February 1969
the visual field. We cannot rule out glau-
coma by testing a predetermined or spe-
cific area in the visual field. A complete
examination of the visual field is best per-
formed by using both static and kinetic
perimetry together. This seems to con-
stitute the best means of modern quanti-
tative perimetry. Scatter of test points can
be controlled only by careful attention to
numerous details involving physical, phar-
macological, physiological, and psycholog-
ical factors, the "chaff" which must be
differentiatied from the "wheat"the pa-
thological patterns to be delineated in
testing the visual field. The factors causing
scatter also influence the reproducibility
of a given visual field from one date to
another, as do the refractive media, pupil
size, mental status, and choice of data
points.
REFERENCES
1. Aulhorn, E., and Harms, H.: Fruhe gesitchts-
feldausfalle beim Glaukom, Tr. Internat.
Congr. Ophth. Munich, 1966, Glaucoma
Tutzing Symposium, Basel, 1967, S. Karger
AG.
2. Drance, S., Wheeler, C, and Fattullo, M.:
The use of static perimetry in the early de-
tection of glaucoma, Canad. J. Ophth. 2: 249,
1967.
3. Garner, Hake, and Eriksen: Operationism
and the concept of perception, Psychol. Rev.
149, 1956.
4. Goldmann, H.: Grundlagen exakter Peri-
metrie, Ophthalmologica 109: 5, 1945.
5. Lynn, J. R.: Current trends in quantitative
perimetry, Internat. Ophth. Clin. 2: 49, 1962.
6. Ourgaud, A. G., and Etienne, R.: L'explora-
tion fonctionnelle de l'oeil glaucomateux,
Paris, 1961, Masson & Cie., Vol. II.
7. Schmidt, T.: Perimetrie relativer Scotome,
Ophthalmologica 129: 303, 1955.
8. Sloan, L. L.: Area and luminance of test ob-
ject as variables in examination of the visual
field by projection perimetry, Vision Res. 1:
121, 1961.
9. Swets, J. A., Tanner, W. P., Jr., and Birdsall,
T. G.: Decision processes in perception, Psy-
chol. Rev. 68:301, 1961.
10. Teichner, W. A.: Recent studies of simple
reaction time, Psychol. Bull. 51:128, 1954.
The early field defects in glaucoma
Stephen M. Drance
The origins of the depression of central isopter known as "baring of the blind spot" as an
early sign of glaucoma were traced. Changes in isopter occurring with aging were reported.
Baring of the blind spot could be produced in everybody with threshold targets and was
therefore not a pathognomonic sign of the disease. A more rapid depression of the isopter
with ocular hypertension has not yet been demonstrated but remains a possibility. The earliest
changes in eyes with open angle glaucoma that could be discovered with the use of static
perimetry were paracentral scotomas in the Bjerrum area separated from the blind spot,
coalescing into an arcuate scotoma joining the blind spot.
From the Department of Ophthalmology, Uni-
versity of British Columbia, the Department of
Ophthalmology, Shaughnessy DVA Hospital,
and the Glaucoma Clinic of the Vancouver
Ceneral Hospital, Vancouver, B. C, Canada.
This study was supported in part by MRC Grant
MA1578 and in part by DVA Grant 10/63.
A
knowledge of the earliest stages of
damage in a chronic disease process, pref-
erably at a stage when it is still reversible,
seems fundamental to an understanding
and rational management of the disease.
In chronic simple glaucoma, which many
Volume 8
Number 1
Symposium on effect of glaucoma on visual function 85
ophthalmologists will diagnose only when
damage to visual function has occurred,
it is essential to know the earliest repro-
ducible disturbances and their mode of
progression in order to ensure that recog-
nition is not unnecessarily delayed and yet
treatment should not be commenced un-
necessarily early in all ocular hypertension
without an understanding of those factors
which will predict damage to the eye. It
is not certain that reversible changes oc-
cur, though we suspect they do. It is pos-
sible that the production of small nerve
fiber bundle defects may be sudden,
precipitous, and irreversible. Progression
would then be due to the fallout of more
nerve fiber bundles rather than to a more
severe disturbance of those already dam-
aged. It must be remembered that the
nerve fiber bundle defect can occur in
conditions other than glaucoma. Such
changes as a contraction of the isopter
and the consequent baring of the blind
spot are quite nonspecific. They may well
be accentuated and occur earlier in eyes
with elevated intraocular pressure and
might be reversible.
To study early changes in visual func-
tion, a prospective study of people with
all levels of ocular pressures must be
carried out over the years and many
parameters, including the field, must be
recorded. Such studies are in progress but
no concrete results are yet available. Even
for such studies it is crucial to know ex-
actly what the early stages and sequences
of change of the visual field are so that
the field techniques may be set up to give
the answers sought after. Such prospective
studies may be most rewarding in families
of patients with chronic simple glaucoma
because this raises the incidence of ocular
hypertension and might yield a higher in-
cidence of damage of the visual field.
Another way of getting at early changes
is to study those patients who have ad-
vanced damage produced by open angle
glaucoma in one eye and in whom the
other eye does not yet show a visual field
defect but may or may not show rises in
intraocular pressure.
Almost 100 years ago, Von Graefe
1
de-
scribed the paracentral scotoma in the
central field in cases of glaucoma. The
advent of the perimeter then shifted the
emphasis from the paracentral area to the
periphery of the visual field until Bjerrunr
and his disciple Ronne
3
reverted to test-
ing of the visual field with the use of
small stimuli and a 2 meter screen. They
described the classical sequence of the
glaucomatous visual field, including the
arcuate scotoma with nasal step, breaking
through to the periphery and joining the
blind spot. Traquair,'~
G
whose painstaking
quantitative perimetry remains a classic,
introduced the concept of depression of
the central isopter known as "baring of the
blind spot" as the earliest change of
chronic simple glaucoma. This was fol-
lowed by paracentral scotomas with their
dense nuclei separated from the blind
spot. Traquair's concepts from which
"baring of the blind spot" were developed
and their relationship to the early
li 1500-
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
AGE IN YEARS
Fig. 1. Linear regression of visual field area on
age in 134 eyes. The broken line shows the 95
per cent confidence interval for the means of any
age while the confidence interval of the individual
readings is shown by the faint solid line.
86 Drance Investigative Ophthalmology
February 1969
Nomen: S. F. Age 67
Datum: May 11/1965
Diagnosis: normal
2 c - 63%transmisj.
Fig. 2.
63 per
Visual field in a 67-year-old normal man. The I
2
Goldmann target was used with a
cent transmission filter, baring of the blind spot occurred.
L EYE
30 30
10 20 30
Fig. 3. Right: static profiles along 3 meridians showing 2 absolute paracentral scotomas. There
is a relative scotoma 2 from fixation in the 45 meridian. Left: kinetic plot shows the sco-
toma and nasal step. The small superior and relative scotoma could not be plotted kinetically.
Volume 8
Number 1
Symposium on effect of glaucoma on visual function 87
ft. '
Fig. 4. Upper: static profiles showing dense para-
central scotoma. Lower: shows that the dense
scotoma is surrounded by extensive areas of rela-
tive depression. On nasal side scotoma comes to
within 3 from fixation.
sis of chronic simple glaucoma should be
analyzed. In order to set the scene, I
would like to quote from his very exact
writings: (1) "The forms of glaucoma re-
ferred to as subacute, acute congestive, or
inflammatory are to be regarded as ex-
acerbations in simple glaucoma from
which they differ only in violence but not
in essential nature."
5
(2) "The most usual
symptom of which the patient complains
is the presence of recurrent dimness of
vision in one eye. This may last for a few
hours or a day but disappears spontane-
ously. These symptoms indicate exacerba-
tions of pressure and may be present for
many years before a subacute or acute
attack of glaucoma occurs or before cup-
ping of the disc or change in the field of
vision develop."
5
These two statements
indicate that, as angle closure and chronic
simple glaucoma were not differentiated,
the bulk of his patients had angle closure
glaucoma and that the proof of an eye
having early glaucoma was the subsequent
occurrence of an acute attack.
He then stated that "since glaucoma is
a bilateral disease, we search for the early
stages in the apparently healthy eye of a
patient who has undoubted glaucoma in
one eye,"
1
and divided the eyes in which
no obvious visual field defects were pres-
ent into 5 groups: (1) "the suspected
eye," which was in every way normal and
healthy but was suspect because of defi-
nite glaucoma in the other eye; (2) eyes
with no field defects in whom a history of
halos and ocular discomforts and other
suggestive features were present but with
a normal optic nervehead and normal in-
traocular pressure; (3) eyes with cupping
or pallor of the optic nerve found during
routine examination; (4) increased pres-
sure alone on routine examination; and
(5) various combinations of the above.
This group of people was then investi-
gated with the smallest visual angles and
the depression of the central field or bar-
ing of the blind spot was elucidated. He
stated, "it (baring of the blind spot) is
the earliest field change I have found in
cases of suspected glaucoma. It is interest-
ing to note that, although baring of the
blind spot is undoubtedly the precursor of
the arcuate scotoma, the arcuate scotoma
does not appear to go out of the baring
but seems to arise independently as a
small curved scotoma on or about the 15
circle, a little distance from the blind
spot. The baring of the blind spot may be
present in the upper part of the field with
an early arcuate scotoma in the lower
part."
5
Traquair therefore examined mostly
second eyes of patients who had estab-
lished angle closure glaucoma in the first
eye or who had prodromal symptoms of
angle closure glaucoma in an eye which
had not yet been damaged. One of the
main pieces of evidence for baring of the
Drance
Inoestigatioe Ophthalmology
February 1969
Fig. 5. Upper right and left: Absolute scotoma in Bjerrum area surrounded by relative scotoma.
Lower left: shows kinetic plot of the area. Lower right: circular static plot 14 from fixation
shows that the absolute nucleus is separated from blind spot by a relative scotoma.
blind spot being a precursor of the classi-
cal field defects of chronic simple glau-
coma was the fact that many of Traquair's
patients developed acute or subacute at-
tacks of glaucoma within two or three
years. Traquair himself stated that classi-
cal arcuate scotoma often occurred in the
opposite part of the field from that which
bared the blind spot.
The aging process, with changes in
pupil size, changes in the clarity of media,
narrowing of the palpebral aperture, and
possibly some changes in the neuroretinal
mechanism, leads to a diminution of the
entire visual field with advancing years.
7
In addition, the slope of the field around
the blind spot is flattest.
8
Small visual
angles become threshold stimuli for many
older normal individuals and it is charac-
teristic of examinations with threshold
targets that classical baring of the blind
spot, more often above than below, de-
velops as part of the change in the isopter
(Figs. 1 and 2). We were able to establish
baring of the blind spot in almost every-
body, young or old, by choosing threshold
targets. Standard targets, such as the
1/1,000 or 1/2,000 or the 2/1,000 or
2/2,000 or Goldmann targets Ii or I
2
, will
be threshold for some individuals with
aging and must be expected in them to
bare the blind spot at that time. This type
of visual field defect can therefore not be
considered as an entity indicating early
damage from chronic simple glaucoma.
The fact that in chronic simple glaucoma
or in ocular hypertension there may be a
more rapid change in the isopter and
retinal sensitivity could be true, but has
not as yet been established.
Taking our cue from Traquair we car-
ried out a study, choosing a group of
people in whom one eye showed the ad-
vanced changes of open angle glaucoma,
with an atrophic nervehead and a very
advanced classical glaucomatous visual
field defect in the presence of a normal
angle, in whom the other eye was appar-
ently not damaged to a 1 mm. or 2/1,000
white target.
9
Static and kinetic perimetry
was performed with the use of the Tubin-
gen perimeter to plot the photopic visual
Volume 8
Number 1
Symposium on effect of glaucoma on visual function 89
Fig. 6. Sequential fields showing the occurrence of fresh paracentral scotomas in an area of
relative disturbance below and in an undisturbed area above. The relative scotomas become
confluent and form an absolute arcuate scotoma still separated from the blind spot.
thresholds at 1 intervals along the
oblique meridians. The entire central
fields were searched diligently for evi-
dence of other scotomas and the kinetic
isopters were plotted at the end. In those
patients in whom the badly damaged eye
had elevated intraocular pressures, one
could assume that any changes found by
the more sophisticated techniques which
eluded preliminary discovery with the
tangent screen are likely to be early mani-
festations of chronic simple glaucoma. The
classical changes in the second
10
eye were
found to be small absolute paracentral
scotomas with their long axis usually di-
rected in the line of the arcuate nerve
90 Drance
Investigative Ophthalmology
February 1969
Fig. 7. Visual fields carried out 4 months apart showing change of relative scotoma into an
absolute paracentral scotomas (5 above fixation).
fibers surrounded by a zone of relative
scotoma and separated from the blind
spot either by a completely normal field or
a very much less disturbed area of visual
functions (Figs. 3, 4, and 5). These para-
central scotomas often come to within 2
to 3 fixation on the nasal side and were
usually further away from fixation on the
temporal side. They occurred in the classi-
cal Bjerrum area although they did not
form a complete scotoma at this stage.
Some patients had a similar type of defect
in the same locations but the defect was
only relative. These relative defects were
more difficult to interpret and their sig-
nificance and progress are being evalu-
ated at this time. Such scotomas can occur
in people who do not have any evidence
of glaucoma in either eye; we have noted
them to correspond to cotton wool exu-
dates seen after severe gastrointestinal
hemorrhage and systemic hypertension.
We have not found the classical Seidel
scotoma, which is a scotoma arising from
the blind spot, following a slightly curved
course and being widest at the blind spot
and then tapering out in a pointed way
away from the blind spot. Traquair stated,
"I have never been able to establish the
presence of defects of this kind, even by
serial testing."
Traquair believed that the true arcuate
scotoma arose quite quickly and was often
quite a large defect when first noticed.
"It seems extremely difficult to detect its
first appearance and to trace its early de-
velopment, though I have observed many
cases of glaucoma and never been able to
follow its growth step by step and for this
particular reason, I believe it develops
rapidly." It is our impression at this time
that most of the paracentral absolute
scotomas in the Bjerrum region do in fact
develop quickly as one would expect from
the fact that they are vascular in origin
(Fig. 6).
We have, however, many recorded
sequential fields in which relative nuclei
became gradually denser and ultimately
absolute side by side with the occurrence
Volume 8
Number 1
Symposium on effect of glaucoma on visual function 91
of fresh defects (Fig. 7). If the occur-
rence of maximal defects were the only
sequence occurring in glaucoma then the
chances of finding reversible and predic-
tive signs in the visual field would be
small and unlikely, but the early incom-
plete evidence, such as we have at this
time, suggests that established defects do
undergo change; this gives us hope that
by employing more sophisticated physio-
logical parameters of visual function such
as spatial, temporal summation, size of
receptive field, and their change with
states of adaptation may lead to a reliable
predictor during a reversible stage. This is
being investigated at this time in our
laboratories and clinics.
REFERENCES
1. Von Graefe, A.: Beitrage zur Pathologie und
Therapie des Glaukoms, Arch. J. Ophth. 15:
108, 1869.
2. Bjerrum, J.: t)ber eine Zufugung zur gewo-
hnlichen Gesichtsmessung und iiber das Ge-
sichtsfeld beim Glaukom, 10th Internat. M.
Kongr. Berlin, p. 66, 1890.
3. Ronne, H.: Uber das Gesichtsfeld beim Glau-
kom, Klin. Monatsbl. Augenh. 47: 12, 1909.
4. Traquair, H. M.: Perimetry in the study of
glaucoma, Tr. Ophth. Soc. United Kingdom
51: 585, 1948.
5. Traquair, H. M.: Glaucoma with special ref-
erence to medical aspects and early diagno-
sis, Brit. M. J. No. 3906, 922, 1935.
6. Traquair, H. M.: Clinical detection of early
changes in the visual field, Am. Arch. Ophth.
22: 947, 1939.
7. Drance, S. M., Berry, V., and Hughes, A.:
The effects of age on the central isopter of
the normal visual field, Canad. J. Ophth. 2:
79, 1967.
8. Aulhorn, E., and Harms, H.: Early visual
field defects in glaucoma, in Glaucoma, Basel,
1966, S. Karger, Ltd., p. 151.
9. Drance, S. M., Wheeler, C, and Pattullo,
M.: Uniocular open angle glaucoma, Am. J.
Ophth. 65: 891, 1968.
10. Drance, S. M., Wheeler, C, and Pattullo,
M.: The use of static perimetry in the early
detection of glaucoma, Canad. J. Ophth. 2:
249, 1967.
The Bjerrum area in ocular hypertension
R. M. H. Pinkerton
Circular static perimetry was carried out on preselected points in the Bjerrum area on normal
eyes and eyes with ocular hypertension. It was found that in the normal subject there was a
decline in sensitivity with age, most particularly marked in the upper field. Eyes with ocular
hypertension showed more reduction in sensitivity than normal eyes in the same age group. It
is postulated that in ocular hypertension there is premature aging of the field in the Bjerrum
W,
e have yet to establish a definition of
the glaucomatous state and lacking this
we are even less able to define the condi-
tions variously called ocular hypertension,
preglaucoma, or glaucoma suspect. For the
From Queens University, Kingston, Ont, Canada.
Supported in part by Ontario Provincial Public
Health Grant 605/9/258 (glaucoma clinic).
purposes of this study, ocular hypertension
was defined as follows: tension: 21 to 25
mm. Hg, with a 4 to 5 mm. rise on water
drinking; tonography: C values 0.12 to
0.20 before or after water drinking, and
Po/C values 100 to 150; optic disc: no
ophthalmoscopically visible abnormality;
visual fields: no abnormality detected on
kinetic Goldmann perimetry; family his-
tory: no known family history of glaucoma.