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To determine the association between change from baseline in the optic nerve head (ONH) and the visual field (VF) during follow-up of ocular hypertension participants in the Ocular Hypertension Treatment Study.Longitudinal randomized clinical trial.One hundred sixty-eight eyes of 152 ocular hypertensive participants ages 40 to 80 years.Cox hazard models were applied to 3232 eyes, which included 81 eyes that reached a study end point by developing a glaucomatous VF (VF end point) and 128 eyes that reached a study end point by developing an optic disc change (optic disc end point).Primary open-angle glaucoma end point as determined by changes in the VF or optic disc.Forty-one eyes reached an end point by both VF and optic disc criteria; 40 eyes reached only a VF end point, and 87 reached only an optic disc end point. Times to reach isolated disc or field end points were similar. Visual field end points were more likely (P0.0001) in eyes that showed the following ONH features: an ONH hemorrhage, thinning of the optic disc rim, or enlargement of the horizontal cup-to-disc (C/D) ratio. Optic disc end points were more likely (P0.0001) in eyes that showed the following VF features: some evidence of a nasal step or a partial arcuate VF defect, or an increase in the pattern standard deviation (PSD).Both the VF and the optic disc must be monitored with equal diligence, because either may show the first evidence of glaucomatous damage. Changes in the ONH based on stereophotographic observation (rim thinning, hemorrhage, or a slight increase in C/D ratio) and VF changes (evidence of a nasal step/partial arcuate defect or an increase in PSD) suggest that these cases have an increased risk of developing glaucoma. Confirmation of such subtle findings should be sought through repeat testing and correlation with other clinical results.

Purpose The Ocular Hypertension Treatment Study (OHTS) seeks to evaluate the safety and efficacy of topical ocular hypotensive medication in preventing or delaying the onset of visual field loss and/or optic nerve damage in ocular hypertensive subjects at risk for developing primary open-angle glaucoma. This study evaluates the baseline visual field test characteristics (visual field status, reliability properties, etc.) of patients who underwent eligibility visual field testing for entry to the OHTS. Design Cross-sectional study of baseline data as part of a longitudinal randomized clinical trial. Participants Two thousand eight hundred nineteen ocular hypertensive individuals, aged 40 to 80 (mean age, 55). Methods Subjects underwent at least two Humphrey Field Analyzer Program 30-2 Full Threshold visual field examinations in both eyes for study eligibility. A third examination was performed if a prior test was abnormal, questionable, or unreliable. For final eligibility, two sets of visual field examinations had to meet OHTS criteria for reliability and had to be classified as "normal." All OHTS visual field tests of potential subjects were submitted for eligibility assessment to the OHTS Visual Field Reading Center. Main Outcome Measures The percentage of visual fields that were normal and reliable according to OHTS criteria. Results Of the subset of 2304 subjects who completed the eligibility assessments, 1828 (79%) were OHTS-eligible based on visual field test requirements. A third eligibility test was required for 11% of all eyes because of unreliable, questionable, or abnormal test results. With the 33% fixation loss cutoff in the OHTS, 97% of all eligibility visual field examinations were reliable and 3% were unreliable. The most frequent cause (69.5%) of unreliability was excessive fixation losses. Conclusions Permitting one repeat test after an abnormal or unreliable test allowed an extra 560 patients to be "eligible" for the study based on visual field tests. A clinical screening review of otherwise normal and reliable tests was not restrictive. The adoption of a 33% fixation loss cutoff significantly reduced the number of required retests and prevented study rejection of 89 patients.

PURPOSE: To compare the results of peripheral kinetic visual field testing and central static perimetry for patients enrolled in the Optic Neuritis Treatment Trial to determine (1) whether loss and recovery of visual field sensitivity in the far periphery was different from that observed in the central visual field and (2) whether the far peripheral visual field provided additional useful information that was not available in the central visual field results. METHODS: Both affected and fellow eyes of 448 patients with optic neuritis in the Optic Neuritis Treatment Trial were evaluated according to the trial protocol during the patients' first 3 years in the study. Central static visual field tests were performed with program 30-2 on the Humphrey Field Analyzer, and peripheral kinetic testing consisted of plotting the I 3e and II 4e isopters on the Goldmann perimeter. Both test procedures were conducted according to the trial protocols, and quality control assessments and clinical evaluations were performed on all the visual fields. RESULTS: For both affected and fellow eyes at all 11 visits, there was a greater number of abnormal visual fields in the central static perimetry results than in the peripheral kinetic data. Only 2.9% of affected eyes had an abnormal peripheral visual field with a normal Humphrey mean deviation during year 1. At baseline, 97.1% of affected eyes had an abnormal Humphrey mean deviation on central static testing, whereas only 69.9% had abnormal peripheral kinetic visual fields. Approximately 80% of the I 3e and II 4e isopters for affected eyes that were abnormal at baseline were within normal limits at 30 days, but it took until week 19 for even 70% of the Humphrey mean deviations to return to normal. In addition, the II 4e isopters (more peripheral than the I 3e isopters) that were abnormal at baseline showed a somewhat greater percentage of improvement from baseline through day 30 than the abnormal I 3e isopters. Although this difference is statistically significant, it is probably not clinically significant. For visits after week 19, approximately 25% to 30% of affected eyes had an abnormal Humphrey mean deviation, whereas only 10% to 15% of peripheral kinetic fields were abnormal. CONCLUSIONS: For the affected eye in optic neuritis, the central visual field shows greater abnormalities than the far peripheral visual field. When the results obtained through Humphrey automated central static visual fields and Goldmann peripheral kinetic isopters are compared, the far periphery appears to recover more rapidly and more completely than the central field, at least in more severe cases of optic neuritis. In most cases, recovery in optic neuritis can probably be monitored effectively with automated perimetry of the central visual field alone. However, in cases of severe loss of the central visual field, a peripheral kinetic visual field obtained with a Goldmann perimeter may provide additional information about the patient's vision in the far periphery.

The Visual Field Reading Center (VFRC) was established to assess visual field testing in the Optic Neuritis Treatment Trial (ONTT), to train and certify ONTT technicians, and to monitor the quality of the visual fields through evaluation of the technical aspects of the visual field testing. We describe the functions of the VFRC personnel and the standardized test protocols developed by the VFRC for Humphrey and Goldmann perimetry. We also describe the VFRC procedures for training and certifying visual field technicians, double-checking the eligibility of ONTT patients, assessing the quality of the visual field data, and processing visual field data. In addition, we describe the principles applied by the director and associate director of the VFRC in their clinical classification of the various localized and diffuse visual field defects observed in the Humphrey and Goldmann visual fields. The VFRC has processed more than 14,000 Humphrey and Goldmann visual field tests. The visual field quality control procedures and visual field defect classification process have been shown to be quite reproducible. Through quality control assessment procedures, we have been able to pinpoint a variety of problems at an early stage and promptly implement corrective measures. The standardized test protocols, technician training and certification procedures, and quality control assessment techniques used by the VFRC for the ONTT may serve as a model for future clinical trials employing visual field data as an outcome measure. These procedures can also be used to enhance visual field reliability in ophthalmological practices.

Botulinum A toxin has been used to treat strabismus and a variety of spasmodic neuromuscular diseases. Botulinum toxin treatment of strabismus is not as definitive and stable as the traditional surgical approach, but it has been found most useful in postoperative overcorrection, small deviations, sensory deviations, and acute sixth nerve palsy. This toxin has been effective in the treatment of essential blepharospasm and hemifacial spasm, for which it produces temporary relief of symptoms. In addition, this treatment has been applied to lower lid entropion, myokymia, aberrant regeneration of the seventh nerve, lid retraction, corneal exposure, nystagmus, spasmodic torticollis, and adductor spastic dysphonia.

and Enhancing the Educational Experience John L. Keltner, MD Sacramento, California Stuart L. Fine, MD Philadelphia, Pennsylvania Gary W. Abrams, MD Detroit, Michigan Bartly Mondino, MD Los Angeles, California Standardizing subspecialty fellowship education has been discussed at the annual meeting of the Association of University Professors of Ophthalmology (AUPO) for the past 4 years. In January 2002, the AUPO Board of Trustees appointed a task force and requested a report on a recommendation to the Board of Trustees and to the general membership of the AUPO. The AUPO task force expanded immediately to include members from most of the ophthalmic subspecialty societies. The task force reviewed existing subspecialty society guidelines, exchanged considerable correspondence, convened 5 times, and considered several options. The task force presented its initial findings at the January 2003 AUPO annual meeting and made its definitive recommendations at the January 2004 meeting. From the beginning, the AUPO task force agreed on the important elements of any fellowship training program. These included standardization of educational programs, provision of minimum standards for subspecialty training, protection of the public, protection of fellows and residents, the need to monitor compliance with agreedupon guidelines, and the need to assure enforcement of compliance with guidelines. There was agreement that general guidelines should be developed by the task force, but that subspecialty-specific guidelines would be developed by each subspecialty society. The task force also acknowledged the need for the process to be self-supporting financially. One option considered was to petition the Accreditation Council for Graduate Medical Education to undertake an accreditation process similar to the Residency Review Committee process. However, in an effort to think as broadly as possible, other options were considered as well. One attractive option that has been implemented successfully over the past several years is the process now in use by the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). In reviewing carefully the AAPOS program, the task force was impressed with its simplicity and with the observation that “It works!” At its meetings in January and May 2004, the task force members and subspecialty society representatives agreed to recommend that the AUPO embrace a process similar to that implemented by the AAPOS over the past 8 years. The AUPO Board of Trustees and members accepted the recommendation and charged the task force to make plans to implement a modified AAPOS system in a deliberate manner.

Neuro-ophthalmology is an exceptionally complex field, because it is a subspecialty that encompasses not only ophthalmology and neu­ rology, but uses extensive information from the fields of neurosurgery, radiology, internal med­ icine, pediatrics, otolaryngology, and psychia­ try. Any review of neuro-ophthalmology must incorporate this immense volume of literature. The editors of Current Neuro-Ophthalmology have done a remarkable job in this regard. Current Neuro-Ophthalmology is the ninth in a series of critical reviews of neuro-ophthal­ mology since 1980. It stands as another land­ mark contribution to update practitioners in the field of neuro-ophthalmology. Over 1,800 references from the past two years are well organized under six major subject headings. The editors have involved internationally rec­ ognized leaders in the field to survey the litera­ ture relating to neuro-ophthalmology and dis­ cuss the most important findings in 21 review articles. The text is divided into six major subjects, which include the afferent visual system, oculo­ motor system, pupil, retina, orbit, ocular mani­ festations of neurologic disease, and diagnostic methods. This volume describes current and ongoing research, such as the Optic Neuritis Treatment Trial, which is currently underway and may answer questions about the role of corticosteroids in the treatment of optic neuri­ tis. In the past, neuro-ophthalmology has been a subspecialty, primarily focused on diagnosis but it had little to offer in terms of treatment. This excellent review highlights what has taken place in terms of therapeutic options in the field of neuro-ophthalmology over the past several years. The chapter by Myles Behrens and Jeffrey Odel on optic nerve disorders concerns the use of optic nerve sheath decompression in both pseudotumor cerebri and progressive anterior ischemic optic nerve. Additionally, the authors describe the indications for treatment of trau­ matic optic neuropathy. Patrick Sibony de­ scribes the use of botulinum in various spasms of the face and other uses of botulinum. Peter Savino reviews the recent literature on diseases and abnormalities of the orbit, particularly the various treatment modalities for Graves' ophthalmopathy. These are only a few of the vari­ ous treatment modalities covered in this book. Michael Mega, Jon Ween, and Martin Albert review the current literature on higher visual function and describe the development of newer theories of higher visual function that are experimentally testable and the areas of the brain that can be appropriately identified by newer imaging techniques. There is an excellent chapter on the develop­ ment and maintenance of the eye movement systems by Ronald Tusa and David Zee, as well as a chapter on nystagmus and other ocular movement disorders by L. F. Dell'Osso. Medhorn delineates supranuclear eye movement disorders. John Gittinger has an excellent chap­ ter on non-myasthenic ophthalmoplegia, and there is a well-done chapter on myasthenia gravis by Dieter Schmidt. This chapter contains all the latest information about the treatment of both ocular and systemic myasthenia gravis using immunosuppressive therapy, including azathioprine, cyclosporine, and plasmapheresis. The current thinking regarding the role of thymectomy is also well covered. B. Todd Troost provides an up-to-date review of the literature on migraine and facial pain, particularly relating to the recent basic science literature and the current theories on the causes of these disorders and the various therapeutic approaches that have been recently published. Finally, the chapters on orbital computed tomography and magnetic resonance imaging of the visual system present the latest in the literature regarding neuroimaging techniques in a superb fashion. This chapter will be an invaluable aid to any practitioner of neuroophthalmology. Because this is a multi-authored text, it has

A patient with progressive visual loss associated with swelling of the disc presented the classic clinical picture of Leber's optic neuropathy. The hereditary patterns, diagnostic characteristics and natural history of the disease are discussed. Although there is no efficacious treatment for Leber's optic neuropathy available at this time, correct diagnosis is important for purposes of genetic counselling and avoidance of unnecessary neuroradiologic and surgical procedures.

Superior oblique myokymia is a benign entity that causes intermittent, brief, recurring episodes of monocular shimmering oscillopsia. These episodes may be accompanied by torsional diplopia (unusual) or more likely by the awareness of an ocular tremor of the involved eye. Observation with adequate magnification is necessary to establish the diagnosis.

A 35-year-old woman with a history of early childhood encephalitis and a cerebrovascular accident during childbirth at 29 presented with visual hallucinations of two years' duration. A meningioma was removed from the right middle cranial fossa, and the visual hallucinations ceased. Visual hallucinations are complex phenomena which may arise through stimulation of the visual pathways at many levels. The case report is followed by discussion of various types of visual hallucinations and the theories and evidence regarding their pathophysiology.

The authors evaluate the case of a 20-year-old, four-month-pregnant woman who presented with papilledema and visual field loss, and developed headache, intermittent diplopia and impairment of color vision over the next month. The procedures and considerations leading to the diagnosis of pseudotumor cerebri are discussed, as are the various modes of therapy and their indications.

With the cooperation of the California Department of Motor Vehicles and Synemed, Inc., visual field screening tests were administered to 1,027 eyes of driver's license applicants using the Fieldmaster Model 101-PR automated perimeter. Approximately 5% of the eyes tested demonstrated significant visual field loss. These results indicate that mass visual field screening in a driving population is feasible and may become a valuable technique for early detection of eye disease in large populations. It may also be an important factor in traffic safety.

A patient was referred to the neuro-ophthalmology unit with a diagnosis of Foster-Kennedy syndrome; "papilledema" had been noted in the right eye and optic atrophy in the left. Results of radiographic examinations and lumbar puncture had been normal. The considerations and procedures leading to a correct diagnosis of giant cell arteritis are discussed.

Giant-cell arteritis is a polysymptomatic disease of the elderly. Systemic symptomatology includes headaches, arthralgias, myalgias, tender temporal arteries, jaw claudication, low-grade fever, anemia, anorexia, malaise, and weight loss. Visual loss from anterior ischemic optic neuropathy and diplopia resulting from ischemia of the ocular muscles represents the major ocular manifestations of giant cell arteritis. When the diagnosis is suspected, blood for a sedimentation rate should be drawn, and, if it confirms the clinical impression, high dose prednisone should be started immediately and a temporal artery biopsy performed at a later date. Only by asking the proper questions and suspecting the diagnosis will this preventable form of blindness receive the prompt attention it deserves.

Carotid cavernous sinus fistulas (CCSFs) are a rare entity occurring as a result of head trauma and also spontaneously. The major threat from these fistulas is loss of vision. The authors reviewed 18 cases of direct and dural CCSFs seen over the last 10 years and compared our results with 553 cases treated in the literature. Seventy-one percent of our patients with direct CCSFs had successful balloon embolization. In the literature, successful closure of direct CCSFs has ranged from 58 to 100%. As experience with embolization techniques broadens, morbidity and mortality is reduced. The clinical features, diagnostic procedures, therapeutic options, and complications of treatment of CCSFs are discussed.

The records of 84 patients with functional visual loss (59 adults and 25 children) were reviewed over a six-year period. The patients were between 7 and 69 years of age. In the young patients, psychosocial problems relating to parental divorce, poor school performance and attention-getting behavior were common, while in adult patients, financial gain was present in 51 of 59 (86%) individuals. Over 90% of the claimed abnormalities related to the afferent visual system. Fifty-three percent of the patients had underlying organic problems with functional overlay. Inconsistent test results were the most reliable means of identifying the malingering patients. In California, both ophthalmologists and optometrists are able to declare a patient legally blind as well as visually disabled for the purpose of income tax, workers' compensation, and disability benefits. The potential financial impact of malingering patients is discussed.

Four medical centers collaborated in the development of a course in ophthalmology to present new information and skills to the practicing specialist who is not associated with a medical center. The course is presented in 8 two-day sessions, scheduled Friday and Saturday, four times a year, on a two-year cycle. Thus, the participant loses only four days a year from his practice. This course differs from most of the postgraduate courses currently being offered in that it is designed to update basic specialty knowledge and skills systematically to improve health care delivery.

Between August 1976 and September 1982, more than 34,000 manual and automated visual fields have been analyzed in the Department of Ophthalmology, University of California, Davis. Approximately 27% of these tests consisted of manual kinetic visual fields performed on the Goldmann perimeter, while 73% were conducted using automated perimetry. Automated testing alone, or a combination of automated perimetry and manual kinetic testing (Goldmann perimeter) was usually employed to monitor progression or regression of visual field loss. This paper provides an overview of two aspects of automated suprathreshold static perimetry that have not been emphasized in our previous studies: (1) methodologic difficulties and problem patients in automated suprathreshold static perimetry, and (2) examples of automated suprathreshold static perimetry in neuro-ophthalmologic patient populations.

The Fieldmaster automated perimeter's effectiveness in determining glaucomatous visual field progression was evaluated. One hundred fifty-four eyes with glaucoma (41) and ocular hypertension (113) were followed for two to four years with manual static and kinetic perimetry (Tübingen) and automated suprathreshold static perimetry (Fieldmaster). With Tübingen static testing, 11 eyes with established glaucomatous visual field loss demonstrated progressive field loss and one eye showed improvement. Ten of these 12 eyes showed progression on the Fieldmaster. Two ocular hypertensive eyes demonstrated consistent defects on the Fieldmaster over several years, but were not detected on Tübingen static perimetry. Comparison between Tübingen static testing and Fieldmaster perimetry was good except for four Fieldmaster false alarms.

We compared photogrammetric measurements of optic cup volume, area, and depth made from two types of stereophotography and two types of film to determine their effect on the precision of the measurements. We found that measurements from simultaneous stereophotography (Donaldson stereoscopic fundus camera) had a smaller range of values and a smaller mean percent error than measurements from consecutive stereophotography (Zeiss Fundus Flash II camera). However, a Student's t-test for related measures showed no significant difference. The measurements from Kodachrome 25 film and Kodak Photomicrography film varied in range and mean percent error without a pattern. The Student's t-test for related measures showed no significant difference.

Preliminary investigations of optimal target distribution patterns for automated perimetry were conducted. In the first study, frequency distributions of visual field defects were determined in glaucoma (260 scotomata) and optic nerve disease (110 scotomata) for approximately 30,000 visual field locations. The frequency distributions in glaucoma and optic nerve disease were different, and suggest guidelines for development of target distribution patterns to achieve optimal detection rates. The second study included computer simulation of 20 target distribution patterns currently used in manual and automated perimetry. Each distribution pattern was processed through the 370 glaucoma and optic nerve disease scotomata to assess detection performance. Both the density and distribution of target locations affected overall detection rates. In addition, some target configurations were more susceptible to false alarms than others. These data provide qualitative information for optimization of target distribution patterns in automated perimetry, and serve as a foundation for future quantitative studies.

This study presents a preliminary comparison of six commercially-available automated threshold static parameters, consisting of three projection perimeters (Humphrey Field Analyzer, Squid, and Octopus 500) and three light-emitting diode (LED) perimeters (Dicon 2000, Fieldmaster 50, and Digilab 350). Eighteen individuals were included in the study: 6 normal observers (31–58 years old), six patients with glaucomatous field loss in both eyes (5570 years old), and six patients with neuro-ophthalmologic or retinal visual field abnormalities in both eyes (12–61 years old). Three aspects of quantitative testing were evaluated: (1) the patients' and normal observers' acceptance and subjective impressions of the test procedure; (2) the technician's ease of operating the device and related tasks; and (3) practitioner-oriented considerations such as test-retest reliability, comparability of test results and testing time. Our results showed that no device was clearly superior to the others in all respects. Patients were most favorably impressed with the Octopus 500, Squid, and the Fieldmaster 50, while technician impressions were most favorable to the Humphrey Field Analyzer and the Squid. The projection perimeters (Humphrey Field Analyzer, Squid, and Octopus 500) were the easiest to perform cross-comparisons of test results, although there was considerable variation in the clarity of data interpretation from one case to another. Test-retest reliability and the time of testing varied among the six automated perimeters.

Clinical evaluations of the Autofield-I,8 CFA-120,8 and Fieldmaster Model 101-PRO automated perimeters were performed in comparison with manual kinetic testing on the Goldmann perimeter. All the automated perimeters displayed similar high rates of detecting visual field defects, although their false-alarm (false-positive) rates were considerably different. The principal factors responsible for high-detection and low false-alarm rates are discussed.