How Do Patients Feel About Visual Field Testing? Analysis of Subjective Perception of Standard Automated Perimetry.

PURPOSE: A high rate of unreliability is an issue in visual field (VF) testing, especially in elderly patients, and warrants patient education. We assessed whether subjective perception of the visual field test (VFT) is a good predictor of its reliability in different age groups and examined age differences in patients' awareness of VF damage. METHODS: This cross-sectional study investigated 107 VFT results of 54 patients with glaucoma or ocular hypertension. Subjective perceptions were compared to reliability indices for cooperation analysis and to mean deviation results for VF damage analysis, and an age-segregated sub-analysis was performed. RESULTS: Kappa coefficients showed poor agreement between subjective and objective parameters. Nevertheless, there were age differences. Younger patients had a higher positive predictive value and sensitivity in cooperation analysis and a higher negative predictive value in VF damage analysis. CONCLUSIONS: Patients' perception of cooperation in VFT is a poor predictor of its reliability. Although young cooperative patients may be aware of their good cooperation, even the youngest are unaware of their poor performance. This emphasizes the importance of giving proper directions to all patients during VFT to obtain better reliability indices. Younger, healthy patients are more aware of their health status, than those with a damaged VF, regardless of age. Therefore, illness education is crucial in all glaucoma patients.

Physical Disabilities Related to the Depressive Mental States of Japanese Patients with Subacute Myelo-optico-neuropathy.

Objective The aim of this study was to clarify the clinical conditions related to the depressive mental states in Japanese patients with subacute myelo-optico-neuropathy (SMON), caused by clioquinol intoxication more than 40 years previously. Methods The changes in the mental states with aging were investigated in 25 Japanese SMON patients (mean age: 77.2 years old, range: 53-90) using a Japanese version of the Zung Self-rating Depression Scale (J-SDS) questionnaires with supportive interviews by the clinical psychotherapist and medical checkup records. These mental and medical examinations were repeated more than twice within 2 to 11 years' interval. The J-SDS questionnaires were also examined in 25 age-matched non-SMON elderly people. Results The total J-SDS scores of most of the SMON patients decreased with age without significant changes in the mean Barthel index scores during this study period. The mean J-SDS scores at the first and latest studies were significantly higher than in the age-matched healthy elderly people. The total J-SDS scores of the latest study were significantly correlated with the degree of physical disability, such as the inverse total Barthel index scores, severity of SMON or gait disturbance, but not with the age. Conclusion The total J-SDS scores of most of the SMON patients tended to decrease with age. Repeating mental supportive interviews and medical examinations by experts helped to improve the depressive mental state and revealed close relationship between the mental state and the physical disabilities of the SMON patients.

Relationship between Human Immunodeficiency Virus Neuroretinal Disorder and Vision-Specific Quality of Life among People with AIDS.

PURPOSE: Some human immunodeficiency virus (HIV)-infected individuals have evidence of optic nerve or retinal dysfunction that manifests as decreased contrast sensitivity, even with good best-corrected visual acuity (BCVA). This condition, termed HIV-related neuroretinal disorder (HIV-NRD), is a risk factor for vision impairment (BCVA <20/40), blindness (BCVA ≤20/200), and increased mortality. We investigated the effect of HIV-NRD on vision-specific quality of life (QOL). DESIGN: Cross-sectional analysis of data from a prospective, observational study. PARTICIPANTS: Individuals from the Longitudinal Study of the Ocular Complications of AIDS cohort who completed the National Eye Institute 25-item Visual Function Questionnaire (VFQ-25), had BCVA of 20/40 or better, and had no evidence of ocular opportunistic infection or cataract. METHODS: We compared QOL by HIV-NRD status, adjusting for potential confounding variables, using multiple linear regression. Among those with HIV-NRD, we assessed the relationship between VFQ-25 and the logarithm of contrast sensitivity (logCS), using Spearman correlation. We defined a minimum clinically important difference (MCID) as 1 standard error of measurement from a well-characterized, historical population of individuals with a variety of ophthalmic disorders. MAIN OUTCOME MEASURES: Subscales and composite VFQ-25 scores (0 = worst, 100 = best). RESULTS: A total of 813 individuals met study criteria. Those with HIV-NRD (n = 39 [4.8%]) had a lower mean composite score than those without HIV-NRD (81 vs. 89; P = 0.0002) and lower mean scores in the following subscales: near activities (77 vs. 86; P = 0.004), distance activities (85 vs. 91; P = 0.01), social functioning (89 vs. 96; P = 0.0005), mental health (75 vs. 87; P = 0.0001), dependency (81 vs. 94; P < 0.0001), driving (75 vs. 85; P = 0.02), color vision (90 vs. 97; P < 0.0001), and peripheral vision (85 vs. 91; P = 0.0496). Score differences for each of these subscales met criteria for MCID. Among those with HIV-NRD, there was a positive correlation between logCS and composite score (r = 0.36; 95% confidence interval, 0.04-0.60). CONCLUSIONS: HIV-NRD has a statistically significant and clinically meaningful association with decreased vision-specific QOL among people with AIDS and good BCVA.

Frequency Doubling Technology Perimetry and Changes in Quality of Life of Glaucoma Patients: A Longitudinal Study.

PURPOSE: To evaluate the relationship between rates of change on frequency doubling technology (FDT) perimetry and longitudinal changes in quality of life (QoL) of glaucoma patients. DESIGN: Prospective observational cohort study. METHODS: One hundred fifty-two subjects (127 glaucoma and 25 healthy) were followed for an average of 3.2 ± 1.1 years. All subjects were evaluated with National Eye Institute Visual Function Questionnaire (NEI VFQ-25), FDT, and standard automated perimetry (SAP). Glaucoma patients had a median of 3 NEI VFQ-25, 8 FDT, and 8 SAP tests during follow-up. Mean sensitivities of the integrated binocular visual fields were estimated for FDT and SAP and used to calculate rates of change. A joint longitudinal multivariable mixed model was used to investigate the association between change in binocular mean sensitivities and change in NEI VFQ-25 Rasch-calibrated scores. RESULTS: There was a statistically significant correlation between change in binocular mean sensitivity for FDT and change in NEI VFQ-25 scores during follow-up in the glaucoma group. In multivariable analysis with the confounding factors, each 1 dB/year change in binocular FDT mean sensitivity corresponded to a change of 0.8 units per year in the NEI VFQ-25 scores (P = .001). For binocular SAP mean sensitivity, each 1 dB/year change was associated with 2.4 units per year change in NEI VFQ-25 scores (P < .001). The multivariable model containing baseline and rate of change information from SAP had stronger ability to predict change in NEI VFQ-25 scores compared to the equivalent model for FDT (R(2) of 50% and 30%, respectively; P = .001). CONCLUSION: SAP performed significantly better than FDT in predicting change in NEI VFQ-25 scores in our population, suggesting that it may still be the preferable perimetric technique for predicting risk of disability from the disease.

The identification and measurement of autistic features in children with septo-optic dysplasia, optic nerve hypoplasia and isolated hypopituitarism.

This study aimed to highlight the occurrence of autism spectrum disorders (ASDs) in children with septo-optic dysplasia (SOD) and optic nerve hypoplasia (ONH). A cross-sectional study was designed, including 28 children with SOD and 14 children with ONH. Clinician diagnosis of ASD was reported in 14 children. The Social Communication Questionnaire (SCQ) reported that 23 children met the cut-off point for ASD, and 9 children met the cut-off point for autism. Greater levels of intellectual disability and visual loss were reported in children with ASD in comparison to those without ASD, but, of the two, intellectual disability was a better predictor for ASD. The SCQ lost its sensitivity and specificity in children who had greater visual loss which highlights a requirement for a measure that is sensitive to visual loss. It is also recommended that children with SOD/ONH would benefit from routine screening for ASDs.

The Italian version of the Glaucoma Symptom Scale Questionnaire: translation, validation, and reliability.

PURPOSE: To validate the Italian version of the Glaucoma Symptom Scale (GSS) Questionnaire and its symptoms and function subscales. METHODS: This transversal validation study enrolled nonhospitalized patients with glaucoma, and a reference sample of patients without eye diseases. Eligible participants had to be cognitively able to respond to a health status interview. The Italian self-administered versions of the 25-item National Eye Institute-Visual Function Questionnaire and the GSS Questionnaire were administered to all participants. Reliability and validity of the Italian translation of the GSS Questionnaire were tested using standard statistical methods for questionnaire validation. RESULTS: Ninety-seven patients were enrolled. Cronbach α coefficient ranged from 0.72 to 0.92 across subscales and eyes. Test-retest stability was >85% for each subscale and eye. The control group of participants had better scale scores across all dimensions of vision-targeted health-related quality of life captured by the GSS Questionnaire (P<0.05) and there were good correlations between responses GSS Questionnaire subscales and analogous domains of the 25-item National Eye Institute-Visual Function Questionnaire. CONCLUSIONS: The Italian version of the GSS Questionnaire has good validity, discriminatory power, internal consistence and reliability, showing psychometric properties comparable with those of the English version, and can therefore be used in clinical research as a specific measure of vision-related quality of life in Italian-speaking patients with ocular hypertension or glaucoma.

[The neuroophthalmic supplement to the NEI-VFQ: test statistics and validation with a cohort of patients with pre- and postchiasmatic damage]. / Das neuroophthalmologische Supplement des NEI-VFQ: Teststatistische Überprüfung und Validierung an einer Stichprobe prä- und postchiasmatisch geschädigter Patienten.

BACKGROUND: The National Eye Institute Visual Function Questionnaire (NEI-VFQ) is not sufficient to assess vision-related quality of life in patients with vision impairments caused by neuroophthalmic deficits. The neuroophthalmic supplement to the NEI-VFQ is currently only available in an English version. The supplement was translated into German and three items concerning visual field loss were added. MATERIAL AND METHODS: NEI-VFQ and supplement data were collected from 62 pre- and postchiasmatic patients with visual field defects and from 245 healthy reference persons. NEI-VFQ and supplement were psychometrically tested and validated. Relations between visual field variables and vision-related quality of life were assessed. RESULTS: The patient group showed diminished quality of life in 10 NEI-VFQ subscales and in eight supplement items when compared to age-matched healthy controls. Correlations between supplement and visual field diagnostic variables demonstrate moderate relations between visual field loss and deterioration of vision-related quality of life. A Cronbach's α of 0.81 for the supplement can be increased to 0.92 in combination with the NEI-VFQ, the sole application of the NEI-VFQ generates an alpha of 0.93 in this sample. A factor analysis reveals four factors that cover the 13 items capturing the following issues: 'severity/problems due to the visual field defect", "unusual eyelid appearances", "blurry vision/double vision" and "diverse vision of both eyes"; 72 % of the variance can be explained by these four factors. CONCLUSION: The German translation of the neuroophthalmic supplement to the NEI-VFQ captures additional vision-specific problems beyond the sole NEI-VFQ that are often reported by patients with vision impairments after brain damage. Although the relevance of some items can be questioned, nevertheless the supplement qualifies for an enhanced outline of subjective vision impairments that are not included in the previous NEI-VFQ.

Driving cessation and driving limitation in glaucoma: the Salisbury Eye Evaluation Project.

OBJECTIVE: To determine if glaucoma is associated with driving limitation or cessation. DESIGN: Cross-sectional analysis within a longitudinal, population-based cohort study. PARTICIPANTS AND CONTROLS: One thousand one hundred thirty-five ever-drivers between 73 and 93, including 70 subjects with unilateral and 68 subjects with bilateral glaucoma. METHODS: All subjects reported their driving habits during each of 4 study rounds. During the fourth and final study round, subjects were assessed systematically for the presence of glaucoma. MAIN OUTCOME MEASURES: Self-reported driving cessation or driving limitation, including cessation of night driving, driving fewer than 3000 miles annually, or cessation of driving in unfamiliar areas. RESULTS: Fifteen percent of subjects without glaucoma no longer were driving at the end of the cohort study, compared with 21% of unilateral glaucoma subjects (P = 0.2) and 41% of bilateral glaucoma subjects (P<0.001). Multivariate regression analysis showed that bilateral (odds ratio [OR], 2.6; P = 0.002), but not unilateral (OR, 1.5; P = 0.3), glaucoma subjects were more likely no longer to be driving when compared with subjects without glaucoma. The odds that bilateral glaucoma subjects no longer were driving doubled for every 5 dB of visual field (VF) worsening in the better eye (P<0.001). Driving cessation within the previous 2 years was analyzed using separate multiple regression models, and both bilateral (OR, 3.6; P = 0.004) and unilateral (OR, 2.4; P = 0.06) glaucoma subjects were more likely to stop driving over this period than subjects without glaucoma. Driving cessation associated with bilateral glaucoma was present in 0.82% of the population, or 1 in every 122 individuals. Greater numbers of driving limitations were not more likely among subjects with glaucoma than subjects without glaucoma. However, bilateral glaucoma subjects did attribute more driving limitations to difficulties with their vision than subjects without glaucoma (OR, 2.2; P = 0.02). CONCLUSIONS: Bilateral, and possibly unilateral, glaucoma is associated with significantly higher rates of driving cessation among the elderly. The substantial difference in driving patterns seen with different degrees of better-eye VF damage suggests that minimizing VF loss in the better-seeing eye is associated with better functional outcomes.

Depression in patients with subacute myelo-optico-neuropathy (SMON).

OBJECTIVE: We investigated the psychiatric disorders in subacute myelo-optico-neuropathy (SMON) patients by structured interview. The prevalence of major depressive disorder in SMON patients was estimated by structured interview and using Beck's depression inventory (BDI) questionnaires. MATERIALS AND METHODS: Psychiatric conditions were evaluated in 26 SMON patients (9 males, 17 females, mean age 70.7 years) living in Kyoto prefecture through a structured interview given by psychiatrists. BDI questionnaires and clinical symptoms of SMON were investigated in 106 patients, ranging from 51 to 91 years in age (mean, 73.5) with SMON patients living in Kinki area. BDI questionnaires were obtained from 92 age-matched aged healthy people, ranging from 57 to 91 years in age (mean, 75.8), living in Kyoto city. RESULTS: Among the psychiatric disorders in SMON patients, the prevalence of major depressive disorder and suicidal ideation significantly increased during the period of clioquinol intake and four patients (15.4%) out of 26 SMON patients still suffer from major depressive disorder. The prevalence of major depressive disorder in SMON patients was estimated at 15.1% (16/106) and this percentage was about seven times as frequent as in the age-matched aged healthy people (2.2%; 2/92). In female SMON patients, the degree of the depressive states was significantly correlated with the severe degree of dysesthesia of the lower extremities, and it was inversely correlated with the duration of SMON disease and the total scores of the Barthel index. CONCLUSION: This is the first report that shows the prevalence of major depressive disorder in SMON patients at present, which was seven times more frequent than age-matched aged healthy persons.

The symptomatic Pulfrich phenomenon can be successfully managed with a coloured lens in front of the good eye--a long-term follow-up study.

PURPOSE: Many visual symptoms originating from a spontaneous Pulfrich phenomenon can be alleviated by the provision of a tinted lens worn in front of the least affected eye. Here, we report on the long-term outcome of four patients who have been provided with a uniocular tinted spectacle or contact lens. METHODS: The case notes of four cases were reviewed. The review period was at least 5 years in all four cases. RESULTS: In all cases, visual symptoms and perceptual difficulties occurring from the spontaneous Pulfrich effect were completely eliminated over a period of many years. In one case, the relief has been sustained over a 20-year period. CONCLUSIONS: A uniocular tinted lens, or contact lens, provides immediate and lasting relief from the visual difficulties caused by the visual delay underlying the spontaneous Pulfrich effect.

Cognitive and behavioural characteristics in blind children with bilateral optic nerve hypoplasia.

AIM: To describe cognitive and behavioural characteristics in a group of blind children with bilateral optic nerve hypoplasia (ONH). METHODS: Data from records, parents, teachers, and repeated developmental assessments of 13 blind children with ONH born in 1988-1998 were analysed. All children had neuroimaging and/or hormonal evidence of midline malformations. They were all blind and able to communicate with speech. RESULTS: Severe mood swings and temper tantrums were common, especially during the first years of life. Later in life, sluggish tempo, low frustration tolerance and a narrow range of interests were common. Autism had been diagnosed in 6/13 children, autistic-like condition (ALC) was found in another three. The behaviour of the remaining four children was not within the autism spectrum. Eight children had cognitive capacities within the normal or near-normal range; five had mental retardation. Autism/ALC was found in all cognitive subgroups. All children exhibited fluent speech and, of these, 12 had started to talk at the expected age, but had clear deficiencies in communicative ability. CONCLUSION: These children had a common pattern of behavioural characteristics including autism spectrum disorders independent of intellectual capacities.

Atypical presentations of ocular toxoplasmosis.

The diagnosis of ocular toxoplasmosis is based most often on the presence of characteristic clinical findings, which include focal retinochoroiditis, an adjacent or nearby retinochoroidal scar, and moderate to severe vitreous inflammation. However, a variety of less common, "atypical" presentations may be unfamiliar to clinicians, delaying both diagnosis and treatment. Patients who are immunocompromised or elderly may, for example, present with large, multiple and/or bilateral lesions. Other unusual manifestations include punctate outer retinal toxoplasmosis, retinal vasculitis, retinal vascular occlusions, rhegmatogenous and serous retinal detachments, a unilateral pigmentary retinopathy mimicking retinitis pigmentosa, neuroretinitis and other forms of optic neuropathy, and scleritis. Although in the past most cases of ocular toxoplasmosis were considered to result from reactivation of a congenital infection, it is now believed that postnatally acquired infection accounts for many cases of this disease. With appropriate use of antiparasitic therapy, the visual prognosis for patients with both typical and atypical forms of ocular toxoplasmosis may be good.

[Psychophysical symptoms of demyelinating diseases of the optic nerve in multiple sclerosis]. / Psikhofizicheskie simptomy demieliniziruiushchikh porazhenii zritel'nogo nerva pri rasseiannom skleroze.

Visual system channels were examined in 25 patients with multiple sclerosis. A new complex of symptoms was detected, reflecting the acute stage and the chronic demyelinizing process, which includes disorders of contrast, color, and spatial contrast sensitivity and stereoscopic vision. This can be useful in differential diagnosis of optic nerve diseases and evaluation of the visual system function in multiple sclerosis and prediction of the disease course.

Motion perception in optic neuropathy.

We tested motion perception in 15 eyes of 13 patients with optic neuropathy. Eleven of the eyes had optic neuritis. The motion perception paradigm tested subjects' ability to discriminate the direction of a global coherent motion signal amid varying levels of background noise. The results showed defective motion processing in eight of the 15 eyes. This defect was not due to low visibility (poor spatial resolution), since 11 of the 15 eyes had Snellen acuities of 20/20 or better. Neither was impaired motion perception due to decreased luminance sensitivity, since attenuating the display signal by 2.1 log units (0.6 units more than the worst relative afferent pupillary defect in any patient) in five normal eyes had no effect. Motion perception and critical flicker fusion were independent of each other. Given proposals that both depend exclusively on the same M, or transient, channel, we had not predicted this double dissociation between flicker and motion perception.