 Okay, it's eight o'clock, so we're gonna get started here. We have a number of visiting medical students today, so this is their time to impress you. So thank you for attending and for your attention. So our first presenter is Jamie Odden. She's a fourth year medical student at the University of North Dakota, and she will be presenting to us on central and peripheral visual field concordance in glaucoma. All right, well, thank you for having us here presenting at Grand Rounds. So our research team has no disclosures to make. So I'm Jamie Odden, I'm a visiting medical student from North Dakota, and this is some work that I did at Hopkins with Dr. Romelu. So we're gonna talk about central and peripheral visual field testing in glaucoma patients. Specifically, does static peripheral testing add useful information to that game from central testing? Sorry for the graphics, I realized that it's a little bit skewed from how I created it. All right, so peripheral visual field predicts some functional outcomes better than central visual field. For example, a prior study dealing with falls showed that peripheral visual field mispoints were associated with greater odds of falling, and central visual field mispoints were not. And peripheral visual field testing can be used to determine suitability for operating motor vehicles. However, visual field testing within the central 30 degrees has become the standard. Now, why is this? Well, normal patients tend to have greater variability at more peripheral points. And central testing just takes less time, so leads to overall lower patient fatigue ability and better results. And prior studies have shown that peripheral kinetic defects occur in about 4% of patients with suspect or early glaucoma and normal central visual fields. Okay, so with this, we asked two research questions. How correlated are peripheral and central visual field loss? And how does the difference between central and peripheral visual field loss vary by disease stage? So this is a sub-study of the falls in glaucoma study at Walmart. We analyzed 232 eyes of 232 patients. Subjects did both central threshold 24-2 testing, as well as peripheral super threshold 30-60 testing. The primary analysis was done in the Vetterai, sensitivity analysis was done in the Worsi. Now, a couple challenges exist when trying to compare these two tests. So first, the central testing uses thresholding and peripheral testing uses super thresholding. Second, the test patterns of these two tests have a different number of points. And so we use the percentage of central and peripheral miss points and calculated that for each subject. So for both tests, we define a missed point as a point that was not seen with the stimulus six decibels brighter than the expected sensitivity at a given test location. Now, the peripheral test, it gives us this directly. But for the central test, we redefine a miss point as a point that is missed based on pattern deviation value. So if the pattern deviation value is less than or equal to negative six, it was counted as missed. Now, you can see the test patterns up here peripheral on top, central on the bottom, they have a different number of test points. And so we use percentages for direct comparison. All right, so what did we find? So in answer to the first question, how correlated are the proportion of miss points in central and peripheral visual field? We found the strongest correlation when comparing the total regions, as shown in the yellow. And these are correlation coefficients. We found weaker correlations when comparing the same hemispheres, as shown in the dark blue. And we found the weakest correlations when comparing across hemispheres, as shown in sky blue. All right, so here's a graph of the correlation. We, so this is not showing up, but we have percent central abnormal points on this axis or here y axis against the percent peripheral abnormal points. And you can see that they are moderately correlated. However, for some eyes, there actually is quite the variability. The difference is quite significant. Now, how about for the second question? How do they differ across disease severity? And so, again, I apologize. I don't know why the y axis is not showing up on this graph. So let's see, it's not gonna, okay. So this one is going to be percent peripheral minus percent. This is gonna be percent central and it's percent peripheral this point. And then we take the same two measures and we take the average of them. Okay, so we have a difference versus an average. And the average can be thought of as like surrogate for disease severity. Now, a couple of things to note on this plot. The difference, the average difference is very close to zero. However, we see a wide range, plus or minus 50%. And then if we look across disease severity, at an early disease stage, we tend to see more peripheral miss points compared to central miss points. And then in late disease stage, we tend to see the opposite, it's kind of interesting. We tend to see more central miss points compared to peripheral miss points. All right, so what if we take a patient from this region of the plot? What might their visual fields look like? Okay, so here's an example. You can see over here on the left, there's quite diffused central loss. Yet peripherally, there is significant peripheral swearing, especially in the oral region. All right, so what about this region on the plot? What might the visual fields look like for a patient? Well, here we see a significant peripheral defect on the right there. Yet centrally, the visual field looks quite normal. So in conclusion, when we look at the correlation, we find that central visual field testing is moderately correlated with that of peripheral visual field, but there could be quite significant disagreement for some eyes. And so it might not be a perfect measure of function of a patient. And then how about for a disease stage? So for early disease stage, we see more peripheral miss points that are maybe not captured on the central testing. So perhaps we could add, integrate these into screening tests for patients. And then in later disease, we see quite the opposite. We see that a subject can have quite significant peripheral swearing despite advanced central loss. So perhaps this may play a role in monitoring disease progression when a patient doesn't have many more points to miss on the central visual field. So there are some issues that we'll consider with our study. No lens was used for the peripheral test for manufacturing recommendations. So we might expect a systematic bias toward more peripheral miss points as spherical error increases, but we don't see that. Second, there's no clear way to identify nose and upper eyelid artifacts on peripheral testing and distinguish that from a true peripheral defect. However, when we just analyzed hemifields that would not be subject to these artifacts like the temporal and inferior regions, we still saw comparable findings. And then there's a learning effect in peripheral testing, but this also occurs in central testing as well. Okay, so at this point, we can take any questions that you have. That was a very nice talk. I was looking for the peripheral testing, was that something that was done using the hypervisual field machine? And is that something that you will raise their practice or is there something that needs more? Yeah, definitely. So this was all static testing, which is kind of unique to the study in the past. It was kinetic testing. And so yeah, it was done on the same on peripheral field. And we kind of tested some algorithms first like different peripheral testing patterns. And ended up with this one. It didn't take much time, about two and a half minutes per eye. Do you think that has the potential to pick up like real early feedbacks when demonstrating that there is a lot more than we should have otherwise done? Well, that's what these findings perhaps suggest. And we're gonna investigate that further. We're looking into more of like the functional measures and all they're associated with peripheral versus central loss as well. Things like exercise, gauge, stability, reading speed. Does peripheral visual field play a little bit more of an important role? And also we can think of maybe not just running a full peripheral test. Maybe we could also integrate peripheral test points say if a person gets a certain amount wrong on the normal screening test. Does that make sense? In the example that you gave with the patient who had fairly advanced glaucoma, like all of their points on the central test were 60B below normal. And I wonder if there's a fallore effect there. Like if you reach that severity of glaucoma that size three stimulus just is to end and catch a progressive disease. Definitely, that's another implication. You know, if to monitor disease progression using this test 24 two, there's not much of a change that you can detect in a long run, right? Yeah, no, I just meant that there's statistically when you're comparing this to the peripheral test that you've kind of the floor with this test. Okay, so I'm not sure if this will answer your question but that's one of the reasons we chose to use pattern deviation value. He said the total deviation value. Okay. So I kind of guess for that it defeats loss. Okay. Okay, thank you very much. Yeah, thank you. Thank you. Thank you.