Macular Function Macular Function Surveillance RevisitedSurveillance Revisited

Rick Trevino, ODRick Trevino, OD

VA Outpatient ClinicVA Outpatient Clinic

Evansville, INEvansville, IN

Fine SL, et al. Ophthalmology. 1985;92:603-609.Fine SL, et al. Ophthalmology. 1985;92:603-609.

Macular Function SurveillanceMacular Function Surveillance

Earlier intervention Earlier intervention improves outcomeimproves outcome– Argon LaserArgon Laser– Photodynamic TherapyPhotodynamic Therapy– Anti-VEGFAnti-VEGF

Home surveillance of Home surveillance of macular function can macular function can result in earlier result in earlier detection of the detection of the symptoms of CNVsymptoms of CNV

More effective in More effective in younger patientsyounger patients

Marmor MF. Surv Ophthalmol. 2000;44:343-353.Marmor MF. Surv Ophthalmol. 2000;44:343-353.

Macular Function SurveillanceMacular Function Surveillance

Richard Förster (1862)Richard Förster (1862)

Marc Amsler (1953)Marc Amsler (1953)

Ted Schlaegel (1968)Ted Schlaegel (1968)

MPS (1983)MPS (1983)

Entoptic Perimetry (2000) Entoptic Perimetry (2000)

Hyperacuity Perimetry Hyperacuity Perimetry (2003)(2003)

Computerized Amsler Computerized Amsler Grid (2004)Grid (2004)

Schuchard RA. Arch Ophthalmol. 1993;111:776-780.Schuchard RA. Arch Ophthalmol. 1993;111:776-780.

Disadvantages of Amsler GridDisadvantages of Amsler Grid

Low SensitivityLow Sensitivity– 50% of scotomas missed50% of scotomas missed

– Only 30% of pts on Amsler Only 30% of pts on Amsler surveillance that develop CNV surveillance that develop CNV detected their lesion using the detected their lesion using the grid grid (Zaidi, et al. Eye. 2004;18:503.)(Zaidi, et al. Eye. 2004;18:503.)

Completion PhenomenaCompletion Phenomena– Perceptual filling-in of defectsPerceptual filling-in of defects

Eccentric FixationEccentric Fixation

Poor Compliance (50%)Poor Compliance (50%)

Nazemi PP, Fink W, Lim JI, Sadun AA. Retina. 2005;25:446-453.Nazemi PP, Fink W, Lim JI, Sadun AA. Retina. 2005;25:446-453.

Improving the Amsler GridImproving the Amsler Grid

Red GridRed Grid

Threshold GridThreshold Grid

– Cross-Polarizing Cross-Polarizing LensesLenses

– Low Contrast CardsLow Contrast Cards

– Computerized Computerized Amsler gridAmsler grid

Non-Grid Surveillance TechniquesNon-Grid Surveillance Techniques

Environmental Environmental AmslerAmsler

Entoptic PerimetryEntoptic Perimetry

Hyperacuity Hyperacuity PerimetryPerimetry

Internet-based Internet-based ProgramsPrograms

Fine AM, et al. Arch Ophthalmol. 1986;104:513-514.Fine AM, et al. Arch Ophthalmol. 1986;104:513-514.

Environmental AmslerEnvironmental Amsler

Monocular inspection of Monocular inspection of straight lines in your straight lines in your surroundings for signs of surroundings for signs of distortiondistortion– Door framesDoor frames– Telephone polesTelephone poles– Ceiling or floor tilesCeiling or floor tiles– Crossword puzzlesCrossword puzzles– Lines of textLines of text

Encourage pts to develop Encourage pts to develop the habit of monocularly the habit of monocularly assessing their visionassessing their vision

Brown JC, Kylstra JA, Mah ML. Ophthalmology. 2000;107:755-759.Brown JC, Kylstra JA, Mah ML. Ophthalmology. 2000;107:755-759.

Entoptic PerimetryEntoptic Perimetry

Random flickering of black Random flickering of black and white dots on video and white dots on video display (TV “snow”)display (TV “snow”)

Makes scotomas visible to Makes scotomas visible to the patient so they can be the patient so they can be monitored for changemonitored for change

89% more sensitive than 89% more sensitive than Amsler grid in detecting Amsler grid in detecting diabetic macular edemadiabetic macular edema

Home surveillance with Home surveillance with TV or computerTV or computer

Adachi M, Shirato S. Jpn J Ophthalmol. 1994;38:392-399.Adachi M, Shirato S. Jpn J Ophthalmol. 1994;38:392-399.

Entoptic PerimetryEntoptic Perimetry

Advantages – Simultaneous examination of the whole visual field – Subjective experience of visual field defects– Can be performed at home using a conventional TV Can be performed at home using a conventional TV

DisadvantagesDisadvantages– Low sensitivity for congenital or Low sensitivity for congenital or suprageniculate

lesions (blind spot, most hemianopic defects)lesions (blind spot, most hemianopic defects)– Qualitative examinationQualitative examination

Kampmeier J, et al. Klin Monatsbl Augenheilkd. 2006;223:752-756.Kampmeier J, et al. Klin Monatsbl Augenheilkd. 2006;223:752-756.

Hyperacuity PerimetryHyperacuity Perimetry

Utilizes Vernier acuityUtilizes Vernier acuityMore sensitive than Amsler grid More sensitive than Amsler grid in detecting late-stage vision in detecting late-stage vision defects in AMDdefects in AMD– Early AMD (PHP: 30%, AG: 30%) Early AMD (PHP: 30%, AG: 30%) – Interm AMD (PHP: 46%, AG: 52%)Interm AMD (PHP: 46%, AG: 52%)– GA (PHP: 87%, AG: 67 %)GA (PHP: 87%, AG: 67 %)– Wet AMD (PHP: 84%, AG: 80 %)Wet AMD (PHP: 84%, AG: 80 %)

Potentially able to differentiate Potentially able to differentiate pts with CNVpts with CNVHome surveillance?Home surveillance?

http://www.meditec.zeiss.comhttp://www.meditec.zeiss.com

Hyperacuity PerimetryHyperacuity Perimetry

PreView preferential PreView preferential hyperacuity perimeter hyperacuity perimeter – Macular perimetry using a dot Macular perimetry using a dot

deviation signal deviation signal – Tests central 14Tests central 14˚ with 500 ˚ with 500

data points in 5 mindata points in 5 min– Preferential looking analysis:Preferential looking analysis:

Quantitatively maps field Quantitatively maps field defects using artificial defects using artificial distortions of the deviation distortions of the deviation signal signal

– Algorithm analysis of the data Algorithm analysis of the data is designed to detect the is designed to detect the presence of CNVpresence of CNV

Hyperacuity PerimetryHyperacuity Perimetry

AdvantagesAdvantages– Quantitative Quantitative – Positive predictive Positive predictive

valuevalue

DisadvantagesDisadvantages– Requires expensive Requires expensive

specialized specialized equipmentequipment

– Not suitable for Not suitable for home monitoringhome monitoring

Internet-Based ProgramsInternet-Based Programs

Currently available: Currently available: Downloadable AmslerDownloadable Amsler

Great potential for Great potential for newer generation newer generation teststests– Entoptic perimetryEntoptic perimetry– Hyperacuity perimetryHyperacuity perimetry– Threshold AmslerThreshold Amsler

Internet-Based ProgramInternet-Based Program

Free web-based Free web-based entoptic perimetry entoptic perimetry computer programcomputer programRecord scotomas Record scotomas and alert patient to and alert patient to significant changessignificant changesResearch study to Research study to compare defects on compare defects on Amsler grid and Amsler grid and entoptic perimetry in entoptic perimetry in pts with AMDpts with AMD

Home SurveillanceHome Surveillance

Amsler GridAmsler Grid– Reinforce compliance Reinforce compliance

Environmental AmslerEnvironmental Amsler– Make it a habit to check Make it a habit to check

monocular visionmonocular vision

Television Entoptic Television Entoptic PerimetryPerimetry– More sensitive than More sensitive than

AmslerAmsler

Thank You!Thank You!