When  is  Bigger  Be+er?

   
Criteria  for  S3mulus  Size  in  Perimetry   Paul  H  Artes,  PhD   IPS  Melbourne  January  2012  

“Two  Men  Contempla/ng  the  Moon”   Caspar  David  Friedrich,  Dresden,  1820  

0.5  degrees  

“Two  Men  Contempla/ng  the  Moon”   Caspar  David  Friedrich,  Dresden,  1820  

Standard  Automated  Perimetry  (III)  
Insensi3ve  with  early  damage   Highly  variable  with  moderate  damage   Limited  dynamic  range  with  severe  damage    

Standard  Automated  Perimetry  (III)  
Insensi3ve  with  early  damage   Highly  variable  with  moderate  damage   Limited  dynamic  range  with  severe  damage    
Many  alterna3ves  have  been  developed   None  have  been  unequiv  “be+er”  than  SAPIII   HRP,  Matrix,  SWAP,…    

CDF,  1830  

Theoretical
design considerations

testable in small-scale studies

real-world evidence

Better match with visual system  Size of receptive fields Structure of stimulus
Spatial summation

Closer correlation with structure Lower variance between controls
Lower variability over time
Larger useful dynamic range
Higher signal/noise ratio

Higher sensitivity & specificity to damage, and to change over time.

Theoretical
design considerations

testable in small-scale studies

real-world evidence

Better match with visual system  Size of receptive fields Structure of stimulus
Spatial summation

Closer correlation with structure Lower variance between controls
Lower variability over time
Larger useful dynamic range
Higher signal/noise ratio

Higher sensitivity & specificity to damage, and to change over time.

Theoretical
Better match with visual system  considerations
Size of receptive fields
Structure of stimulus
Spatial summation

testable in Closer correlation with structure small-scale Lower variance between controls
studies
Lower variability over time
Larger useful dynamic range
Higher signal/noise ratio

real-world Higher sensitivity & specificity to damage, evidence
and to change over time.

“Wreck  in  Moonlight”,  1835  

What  specific  proper3es   do  we  need  to  demonstrate     in  a  “be+er”  test,     (and  how)?     A  case  study  with  Matrix  Perimetry  

2452

Artes et al.
2452 Artes et al.

IO

IOVS, July 200 maximum and minimum luminance test locations of the 24-2 program maximum and minimum luminance of the stimulus Figure 2. test locations of the 24-2 program of the instrum
Figure 2.

Standard Automated Perim

Standard AutomatedAnalyzer (HFA; was Humphrey Field Perimetry. SAP Ca

FIGURE 1. Spatial and temporal characteristics of the stimuli of FDT2 (left) and SAP (right). With the exception of the foveal stimulus, the stimuli of FDT2 (A) are 5°-square windows of vertical cosine of FDT2 program are shown in Figure 2, alon FIGURE 1. Spatial and temporal characteristicsa of the stimuliwave StudyHumphreyand Testing Sample Matrix program. grating with a spatial frequency of 0.5 cyc/deg (B), counterphase (left) and SAP (right). WithThe foveal stimulusof a circular patch with a the the exception is the foveal stimulus, flickered at 18 Hz (C). Fifteen patients with glaucoma (mean age, 66.3 y stimuli of FDT2of 5°. are 5°-square windows of ms,vertical cosine wave diameter (A) The presentation time is 500 a including ramped 80.6) with early to moderate visual field loss (me Study Sample and Testing grating onsets andspatial of 100 ms. The of 0.5 cyc/deg (B), 100 cd/m2. with a offsets frequency background luminance is counterphase dard], 4.0 dB; range, 0.2 to 16.1) were recru The 18 Hz (C). circular luminance increments with a patch with a flickered at SAP stimuli areThe foveal stimulus is a circulardiameter of coma clinics of the QEII Health Sciences Centre (H Fifteen patients with glaucoma (me 0.43°, presented for 200 ms with sudden ondiameter of 5°. The presentation time islevels and and amplitudes ramped IOVS, Criteria for inclusion in the 7 500 (A) offsets. The backms, including (B, 2 . Canada). July with early 46, moderatewere a c ground luminance is 10 cd/m . Grayscale 80.6) 2005, Vol. to No. study visual onsets andare not toof 100 ms. The background luminance is 100 cd/m2. offsets scale. C) open-angle glaucoma, refractive error within 5 D eq dB; range, The SAP stimuli are circular luminance increments withminimum luminance of dard], 4.0respectively.visual0.2 to 6/1 a diameter of D astigmatism, best-corrected The acuity 16 3 maximum and the stimulus, Health Scien 0.43°, presented for 200 ms with sudden test locations of theThe back- prior experience with shownperimetry and S on- and offsets. 24-2 program ofcoma clinics of the QEIIin and the instrument are FDT1 Canada). Criteria for inclusion in 4 w The main 10 cd/m2. this study levels compare threshold examined over three sessions within a period ofthe ground luminance isobjective of Grayscale was to (A) and amplitudes (B,

Humphrey Field Analyzer (HFA; Carl-Zeissthe sta Standard program 24-2 with Meditec Standard program 24-2 with the standard Goldman (diameter, 0.43°, see Fig. 1). The pri (diameter, 0.43°, see Fig. 1). The principles and pro Standard strategy described previously.1 Standard strategy have been have been describ stimulus intensities are varied and 2 stimulus intensities are varied in steps of 4 in st threshold estimates estimates are obtained a threshold are obtained after maximumtions based on the patient’s responses and the p tions based on the patient’s respon trast to the threshold strategy of the Humphrey trast to the threshold strategy of Standard strategy terminates once the threshold Standard with a given confidence, after has been estimatedstrategy terminates once of presentations. The definition of thegiven co has been estimated with a dB scale the brightest stimulus that the instrument is cap of presentations. The definition of [dB 10 log(maximum intensity/threshold sti the brightest stimulus2 that the ins which, with the HFA, is 3183 cd/m . The test locatio [dB 10 Figure 2, alongside those of program are shown in log(maximum intensit which, with the HFA, is 3183 cd/m2. Humphrey Matrix program.

What  have  we  learned  from  Matrix?   Matrix Perimetry 2453
in  physiologic   range:     Predictable   rela3on  between   thresholds  of   both  techniques  
IOVS, July 2005, Vol. 46, No. 7
maximum and minimum luminance of the stimulus, respectively. The test locations of the 24-2 program of the instrument are shown in Figure 2. FIGURE 3. Comparison between thresholds of FDT2 and SAP. Each data point shows the mean threshold of Standard Automated Perimetry. SAP was performed with a six tests with FDT2 and six Humphrey Field Analyzer (HFA; more tests with SAP. Locations affected by floor effects (where one or Carl-Zeiss Meditec), using the SITA-

What  have  we  learned  from  Matrix?   Matrix Perimetry 2453
in  pathologic   range:     No  discernable   rela3onship   between   thresholds  
IOVS, July 2005, Vol. 46, No. 7
maximum and minimum luminance of the stimulus, respectively. The test locations of the 24-2 program of the instrument are shown in Figure 2. FIGURE 3. Comparison between thresholds of FDT2 and SAP. Each data point shows the mean threshold of Standard Automated Perimetry. SAP was performed with a six tests with FDT2 and six Humphrey Field Analyzer (HFA; more tests with SAP. Locations affected by floor effects (where one or Carl-Zeiss Meditec), using the SITA-

What  have  we  learned  from  Matrix?   Matrix Perimetry 2453
0-­‐dB  es/mates:   similar  propor3ons   (3.0  vs  2.2%)  

IOVS, July 2005, Vol. 46, No. 7
maximum and minimum luminance of the stimulus, respectively. The test locations of the 24-2 program of the instrument are shown in Figure 2. FIGURE 3. Comparison between thresholds of FDT2 and SAP. Each data point shows the mean threshold of Standard Automated Perimetry. SAP was performed with a six tests with FDT2 and six Humphrey Field Analyzer (HFA; more tests with SAP. Locations affected by floor effects (where one or Carl-Zeiss Meditec), using the SITA-

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What  have  we  learned  from  Matrix?  
Artes et al.

IOVS, July 200

FIGURE 4. Test–r FDT2 and SAP. D 5th and 95th per tribution of rete fied by mean thr Smooth curves w the data points b regression to app test–retest interv Dashed diagonal

Comparison of Total and Pattern-Deviation Probability Maps

A comparison of the defect scores test locations of and 24-2 program of the instrument are shown in from the total the pattern deviation probability maps of FDT2 and SAP showed good DISCUSSION Figure 2. overall agreement between both techniques (Fig. 6). In paStandard Automated Perimetry. SAP was performed with a Previous investigations with FDT perimetry tients with relatively early SAP visual field loss (SAP total devi- Carl-Zeiss Meditec), using the SITAHumphrey Field Analyzer (HFA; the technique may possess several potential ation defect scores 30), the total deviation probability maps

maximum ith  M luminance Uniform  variability  wand minimumatrix   of the stimulus, respectively. The

IOVS, July 2005, Vol. flagged a slightly larger other, although SAP 46, No. 7 tions as outside normal limits.

Problem  
Which  test  has  lower  variability?   Which  test  detects  more  visual  field  loss?   Which  test  demonstrates  change  be8er?  
Intensity  scales  are  different.   Thresholding  algorithms  are  different.   Norma3ve  datasets  are  different.   There  is  no  ideal  reference  for  loss,  or  change.    

Signal  /  Noise  Analysis   50, No. 10 IOVS, October 2009, Vol.

auhan

FIGURE 9. (a) The SNR measured between locations At1 October 2009, Vol. 50, No. 10 IOVS, and Bt1 measures how reliably the technique represents the gradient of damage in space (vertical arrow). (b) If B deteriorates over time, such that its deviation at Bt2 becomes equal to that of At1, the gradient in time between Bt1 and Bt2 is equal to that between At1 and Bt1. The ability to

3 dB) with SAP, and from 26.2 to 3.3 ) with FDT2. The relationship between ted for 69% of the variance in the data lation, P 0.001, Fig. 3), and, for sectors

There was a moderately close relationship between the signals of both techniques (Fig. 7a, r2 0.52, P 0.001), but no such relationship between the noise estimates (r2 0.01, P 0.16; Fig. 7b).

n this extenld, both SAP ll difference ctively) benferior paraP, the large ors (SD, 3.7 distinguish With FDT2, e clearly apy because of ertical gray in Figure 4.

auhan

IOVS, October 2009, Vol. 50, No. 10

3 dB) with SAP, and from 26.2 to 3.3 ) with FDT2. The relationship between ted for 69% of the variance in the data lation, P 0.001, Fig. 3), and, for sectors

There was a moderately close relationship between the signals of both techniques (Fig. 7a, r2 0.52, P 0.001), but no such relationship between the noise estimates (r2 0.01, P 0.16; Fig. 7b).
4706 Artes and Chauhan

FIGURE 9. (a) The SN sures how reliably the space (vertical arrow deviation at Bt2 becom between Bt1 and Bt2 is detect the change from the SNR between At1

FIGURE 8. Relationship between SNRs with SAP and FDT2. The points labeled A, B, C correspond to the examples in Figures 4, 5, and 6, respectively. Axes are drawn on a square-root scale to emphasize mid-range values.

n this extenld, both SAP ll difference ctively) benferior paraP, the large ors (SD, 3.7 distinguish With FDT2, e clearly apy because of ertical gray in Figure 4.

auhan

of loss, the variability of the measurements, and the dynamic range of the technique. A larger SNR therefore does not necessarily mean that one technique is more sensitive than another, nor does a more sensitive technique necessarily provide a larger SNR (Fig. 10). The signal/noise methodology proposed in this article has several limitations. To obtain robust estimates of signal and noise, multiple tests have to be performed. Nevertheless, a rigorous protocol with at least five examinations per eye has advantages also for the derivation of test–retest intervals, because a large number of combinations of test–retest examinations can be analyzed.26,48 SNRs depend on the sample of patients and therefore cannot be compared across different studies. They also depend on the somewhat arbitrary choice of where in the visual field the signal and noise distributions are derived from. In this study, we used the superior–inferior sectors of the Glaucoma Hemifield Test, and therefore our finding of larger SNRs with FDT2 may strictly apply only to those analyses that make use of a similar clustering. In principle, however, other pairs of test locations or pairs of clusters could be chosen. Finally, SNRs can be estimated only if focal

losses are present sensitivity do not c method is unsuitabl nantly uncover diffu The assumption t approximation for c as yet, untested. Sign will therefore not re new visual field tes coma, but they may cannot be gained so They may help in hy longitudinal studies

IOVS, October 2009, Vol. 50, No. 10

What  have  we  learned  from  Matrix?  
Similar  dynamic  range   Similar  separa3on  between  controls  and  pa3ents   More  uniform  variability   Higher  cross-­‐sec3onal  signal/noise  ra3os     Progression:     Goren  et  al.,  IPS  2012:  similar  rates  of  change   Redmond  et  al:  similar  %  with  significant  change      

What  have  we  learned  from  Matrix?  
Several  desirable  proper3es,  but  no  compelling   evidence  of  overall  superiority.   Evidence  on  change  over  3me  is  coming  along…     Ques/on:       Is  it  /me  to  abandon  the  search  for  the   “universally  beOer  test”?  

asb

mm^2
1 10 100 1000

10000

1/16
Goldmann I

1/4
Goldmann II

1 4 16 64 256
64 128 256

stimulus area, mm^2

Goldmann III

0.25 0.354 0.5 0.707 1 1.41 2 2.83 4 5.66 8 11.3 16 22.6 32 Goldmann IV Goldmann V

asb

mm^2
1 10 100 1000

10000

1/16
Goldmann I

1/4
Goldmann II

1 4 16 64 256
64 128 256

stimulus area, mm^2

Goldmann III

0.25 0.354 0.5 0.707 1 1.41 2 2.83 4 5.66 8 11.3 16 22.6 32 Goldmann IV Goldmann V

G  I   G  V  

Some3mes  even  God  needs   s3mulus  size  V.  

*  Personal  communica3on,  Neil  Armstrong,  July  21,  1969  

Thank  you!  

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