Multifocal pupillographic visual field testing in glaucoma

This preliminary study investigated a means of concurrently assessing the visual field defects of both eyes by recording pupillary responses to multifocal stimuli.

Twenty normal subjects and 26 primary open angle glaucoma patients, age and sex matched, were examined by slit-lamp, Humphrey Field Analyser II achromatic 24-2 perimetry and fundus photography. The patients had moderate to severe fields in at least one eye. Two stereoscopically arranged displays presented an array of 24 stimulus regions per eye extending from fixation to 30 degrees eccentricity. Pupil responses were recorded by video cameras under infrared illumination. Four stimulus conditions were tested: each stimulus region containing either a single or a 2 x 2 array of patches, presented either steadily for 133 ms or flickered at 15 Hz for 266 ms. Mean presentation rate was 1/s/region. The 4-min duration stimuli were presented in 8 segments of 30 s. Segments did not need to be repeated unless more than 15% of a segment record was lost as a result of blinks or fixation losses.

The 48 stimuli produced 96 direct and consensual responses per subject. The single patch, non-flickered stimulus condition produced the best diagnostic performance, an area under the curve of 84%. The contraction amplitudes for that stimulus gave a median z-score of 3.2.

The method produced diagnostic accuracy approaching that of automated perimetry, but unlike perimetry provides standard errors for every point in each field as well as information on response delay and efferent defects. Only one pupil needs to function to measure both visual fields.