Techniques in Ophthalmology 1(4):213–217, 2003
G L A U C O M A S U R G E R Y
Assessment of Visual Function in Glaucoma
Christopher A. Girkin MD
Glaucoma Service, Department of Ophthalmology,
School of Medicine, University of Alabama at
Birmingham.
䊏 INTRODUCTION
Standard visual functional assessment of patients with
glaucoma in clinical practice is typically restricted to
Snellen visual acuity, color vision, and standard achro-
matic perimetry. While these cursory assessments form
the backbone of functional measures in most clinical
settings, and in clinical trials, standard methods of pe-
rimetry are currently limited due to the relatively high
intra-test variability1 with these techniques and limited
sensitivity to glaucomatous changes when compared
with structural alterations of the optic disc and peripap-
illary nerve fiber layer.2,3 A variety of psychophysical
and electrophysiologic measures has been developed in
an attempt to better quantify ganglion cell dysfunction in
glaucoma. This article will focus on the 2 specialized
visual field tests that are most applicable in the clinical
setting: Short-wavelength automated perimetry (SWAP)
and frequency-doubling technology (FDT) perimetry.
䊏 SPECIALIZED PERIMETRY
The development of specialized methods of perimetry
involved modifying stimulus characteristics to fit the
maximal response characteristics of different retinoge-
niculate ganglion cell populations, and it is based on an
understanding of the functional segregation of the reti-
nogeniculate pathway. Functional segregation in the vi-
sual system has its earliest subdivision in the retina. Al-
though over 22 types of retina ganglion cells exist in the
primate retina,4 there are at least 3 types of ganglion cells
involved in visual perception that project to specific lo-
cations within the lateral geniculate nucleus (LGN) and
are also involved in the relaying of information that will
be used by higher cognitive mechanisms in the develop-
ment of conscious visual perception.5 The midget gan-
glion cells have small receptive fields and project to
layers 3 through 6 of the parvocellular LGN. Parasol
Address correspondence and reprint requests to Dr. Christopher A.
Girkin, Department of Ophthalmology, 700 South 18th Street, Suite
601, Birmingham, AL 35233. E-mail: cgirkin@uabmc.edu
Volume 1, Issue 4
© Lippincott Williams & Wilkins, Inc.
cells have much more extensive receptive fields and
project to layers 1 and 2 of the magnocellular LGN. A
third type of retinogeniculate ganglion cell, the bistrati-
fied ganglion cell, projects to the koniocellular layers of
the LGN.6
The parvocellular system (P-pathway) is a static fir-
ing system that conveys information from the retina to
the LGN concerning wavelength selectivity and low-
contrast retinal imagery with high spatial resolution.7,8
High bandpass resolution perimetry (ring perimetry) is
an attempt to selectively evaluate the P-pathway.9
In contrast, the magnocellular system (M-pathway)
conveys high-contrast, low-resolution information that is
colorblind. The magnocellular system is a phasic system
and thus is well suited for the analysis of moving stimuli.
Perimetric techniques, such as frequency-doubled perim-
etry and motion-detection automated perimetry, are used
in an attempt to isolate the M-pathway.7,8 The koniocel-
lular system (K-pathway) conveys information concern-
ing blue-yellow color opponency. SWAP uses a blue
stimulus presented against a yellow background and may
evaluate the responses processed through the K-pathway.
The response characteristics of each ganglion cell popu-
lation are illustrated by photographic manipulation in
Figure 1.
Short-wavelength automated perimetry attempts to
evaluate the responses processed through the K-
pathway (koniocellular system).
Frequency-doubled perimetry attempts to evaluate the
responses processed through the M-pathway (magno-
cellular system).
The M-, P-, and K-pathway inputs, although differing
in response characteristics, have some overlap in the type
of visual stimuli to which they are activated. In addition,
inputs from the parallel systems are processed in a com-
plex and interrelated manner by the visual cortex and
higher cortical centers. Thus, perimetric techniques may
213
 Girkin
FIGURE 1. Visual information that is used to create the
perceived image of a visual scene (top photograph) is
conveyed to the lateral geniculate through 3 pathways.
The lower photographs were manipulated to simulate the
characteristics of the perceived image that are conveyed
along each of these pathways. The parvocellular pathway
(lower left photograph) conveys fine spatial detail and is
thought to be wavelength selective primarily for red and
green opponency. The koniocellular pathway conveys in-
formation concerning blue-yellow opponency and low
spatial detail (lower middle photograph). The magnocel-
lular pathway (lower right photograph) conveys informa-
tion, which is colorblind, of low spatial detail, and sensitive
to motion.
emphasize one pathway over another, but do not com-
pletely isolate the responses processed through a given
pathway. It is important to realize that true functional
isolation of these parallel pathways is not possible and
that these tests represent attempts to emphasis the re-
sponse characteristic favored by these specific popula-
tions of cells.
䊏 SHORT-WAVELENGTH
AUTOMATED PERIMETRY
Initially, when SWAP was developed, it was thought that
information conveyed concerning blue-yellow color op-
ponency was processed through the parvocellular sys-
tem,10 but with the discovery of specific ganglion cells
that demonstrated blue-on yellow-off response charac-
teristics, it became apparent that this is likely primarily a
koniocellular-mediated test.6 Early clinical studies that
demonstrated tritan-like deficits on tests evaluating fo-
veal function in glaucoma stimulated researchers to de-
velop a test to evaluate this short-wavelength system in
214 Techniques in Ophthalmology
the retinal periphery.11 A standard perimeter was modi-
fied to project a 440-nm narrow band size V blue stimu-
lus presented against a broad band 500–700 nm yellow
background for 200 ms to maximize spatial and temporal
summation, further enhancing isolation of the short-
wavelength sensitive pathway.12
Currently, SWAP is the most rigorously evaluated
specialized perimetric technique, and several clinical
studies have been performed with SWAP that illustrate
the test’s strengths and weakness in the assessment of
functional deficits in glaucoma. SWAP defects have
been shown to correlate with structural changes of the
optic disc and peripapillary retina consistent with glau-
coma.13 Neuroretinal rim defects and other signs of optic
disc damage along with retinal nerve fiber layer defects
correlate well with the location and extent of defects on
SWAP and follow the pattern of traditional nerve fiber
layer bundles.14–16 SWAP also compares favorably with
SAP in the correlation to topographic measurements of
the optic disc obtained with confocal scanning laser oph-
thalmoscopy, with mean deviation of SWAP demonstrat-
ing an equal or higher degree of correlation, depending
on which optic disc parameter was used.17
Additionally, 2 independent studies aimed at evalu-
ating SWAP in early detection have demonstrated the
value of SWAP in the detection of visual defects that
precede defect on standard perimetry by 3 to 5 years.18,19
SWAP defects occur in 15 to 30% of patients with ocular
hypertension with normal visual fields by standard pe-
rimetry and correlate with the level of risk categorization
in these patients.20 Furthermore, SWAP defects are more
extensive than defects on SAP in most subjects with
glaucomatous visual field loss. In the Ocular Hyperten-
sion Treatment Study, while there was a higher preva-
lence of SWAP defects, the incidence of the develop-
ment of new SWAP defects was equivalent to that of
SAP, indicating that these 2 techniques are measuring
similar disease processes.21 Additionally, progression us-
ing SWAP corresponds with progression of the optic disc
defined by masked stereophoto graders to a higher de-
gree that standard perimetry.22
Short-wavelength automated perimetry can detect vi-
sual defects that precede defects on standard perim-
etry by 3 to 5 years.
While the initially studies using SWAP demonstrated
an enhanced sensitivity to the detection of early glauco-
matous damage, SWAP has several limitations. SWAP
has shown a higher inter-test variability23 and is more
dramatically affected by cataractous change24 than stan-
 Assessment of Visual Function in Glaucoma

dard achromatic perimetry. Despite this higher variabil-

ity, SWAP has been shown to detect progression at a
similar rate to standard achromatic perimetry, possibly
due to its improved sensitivity.21 Using the pattern de-
viation plots may help in the interpretation of SWAP
visual field defects in patients with significant media
opacities.24 Additionally, the generalized use of SWAP
is limited due to the prolonged testing time associated
with this technique. Testing time usually ranges from 12
to 15 minutes, and the stimulus is more difficult to de-
termine onset and offset due to the slower response char-
acteristics of the koniocellular ganglion cells, which ad-
versely affect patient’s acceptance and fatigue.
FIGURE 2. The frequency-doubling illusion: A luminance
grating of course spatial frequency (1f) in counter-phase
flickered at a high temporal frequency (left), resulting in a
Short-wavelength Automated Perimetry Limitations: perceived stimulus in which the grating has twice the spa-
tial frequency (2f) of the actual stimulus (right).
• Higher inter-test variability
• Dramatically affected by cataractous change
Detection threshold is determined using a modified bi-
nary search bracketed staircase procedure. Fixation is
monitored by blind spot checks using the Heijl-Krakau
These limitations with SWAP have prompted re- method. Each black-and-white stimulus is presented at a
searchers to develop SITA algorithms for SWAP testing spatial frequency of 0.25 cycles/degree and a temporal
that may help reduce both testing time and threshold frequency of 25 Hz counter-phase flicker for 200 to 400
variability.25 This technique has been effective at de- ms with a mean background illumination of 100 cd/m2.
creasing testing time with standard visual field testing The device is self-contained and relatively portable,
and has dramatically reduced the testing time with which enhances its utility in the screening setting. How-
SWAP to under 4 minutes in many patients. However, ever, the unit contains no internal storage, and results are
clinical studies to further define the role of SITA-SWAP either printed out directly or transferred to a computer
in clinical management of glaucoma patients are in their using specialized database software (FDT viewfinder).
early stages. Evaluated as a screening technique, FDT has dem-
onstrated high sensitivity and specificity in the detection
of visual field defects on standard perimetry in glau-
䊏 FREQUENCY-DOUBLING coma.26,29 In addition, FDT has demonstrated more ex-
TECHNOLOGY PERIMETRY tensive visual field defects than SAP in early open-angle
glaucoma,30 in the intact hemifield of normal tension
FDT perimetry was developed as a screening method to
glaucoma patients with altitudinal defects,31 and in re-
detect visual dysfunction in glaucomatous optic neurop-
solved optic neuritis,32 indicating that this technique may
athy.26 It is based on the frequency-doubling illusion
be more sensitive in the detection of ganglion cells dys-
reported by Kelly,27 which describes a doubling of the
function in these disorders.
perceived spatial frequency of a black-and-white grating
when counter-phase flickered at a high temporal fre-
quency (Fig. 2). It was thought that this nonlinear re-
Frequency-doubling technology, evaluated as a
sponse was mediated through a subset of magnocellular
screening technique, has demonstrated high sensitiv-
cells with nonlinear response characteristics (M-y gan-
ity and specificity in the detection of visual field
glion cells); however, whether the frequency-doubling
defects on standard perimetry in glaucoma.26,29 In
effect is mediated through this subset has become a mat- addition, frequency-doubling technology has demon-
ter of debate.28 strated more extensive visual field defects than SAP in
The test is conducted by presenting 8 to 9 FDT pat-
early open-angle glaucoma,30 in the intact hemifield
terns to each hemifield, plus 1 central 5-degree radius
of normal tension glaucoma patients with altitudinal
circular stimulus depending on what mode is selected. defects,31 and in resolved optic neuritis,32 indicating
The additional 2 locations added in the more extensive that this technique may be more sensitive in the de-
test pattern (n-30) cover the nasal step area. These pat- tection of ganglion cell dysfunction in these disorders.
terns are presented in random order with catch trials.

Volume 1, Issue 4 215

 Girkin
There have not been adequate longitudinal studies
using FDT to determine its usefulness in detecting pro-
gressive changes in glaucoma. That the threshold values
are more robust using the FDT is promising33; addition-
ally, the shorter test duration may facilitate more fre-
quent evaluation. A primary limitation of the current
FDT is the limited number of locations tested by the
instruments compared with the standard 24-2 test pattern
used in conventional perimetry. Recently, an FDT pro-
totype has been developed to test in a 24-2 pattern using
a frequency-doubled stimulus.34 Initial studies with this
prototype demonstrated robust threshold measures and
reasonable testing time of around 4 to 5 minutes. A com-
mercial version is currently undergoing evaluation.
Frequency-doubling Technology Limitations:
Limited number of locations tested by the instruments
compare with the standard 24-2 test pattern used in
conventional perimetry.
䊏 CONCLUSION
In summary, techniques designed to emphasize subpopu-
lations of retinal ganglion cells appear to increase the
sensitivity to ganglion cell dysfunction in glaucoma.
Two tests, SWAP and FDT, appear the most promising
for use in clinical practice. However, weakness with each
technique has hampered the widespread use of this tech-
nology. Newly developed models of each of these tests,
which were designed to overcome these weaknesses, are
becoming available for both SWAP and FDT and may
prove useful in the clinical setting. However, widespread
use of this technology awaits validation in currently on-
going observational studies.
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