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Editors Selection IGR 10-3

Perimetry: Vision restoration therapy and improvement VF

Comment by Murray Fingeret on:

22884 Computer based vision restoration therapy in glaucoma patients: A small open pilot study, Gudlin J; Mueller I; Thanos S et al., Restorative Neurology and Neuroscience, 2008; 26: 403-412

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Conventional wisdom holds that once glaucomatous damage occurs, whether in the optic nerve or visual field, the changes are permanent. Still, periodic reports have described a reversal in optic disc cupping, often associated with aggressive glaucomatous therapy and usually cited in congenital glaucomas.¹ Little attention has been paid to visual field reversal but what if some forms of glaucomatous visual field loss may be reversible with therapy. And what if the selected therapy is not the reduction of intraocular pressure but rather a complementary modality in which areas of the retina are visually stimulated. Gudlin et al. (490) investigate the question of whether glaucomatous visual field loss could be improved after individuals undergo vision restoration therapy (VRT), a computer‐based vision training program. This study was an exploratory, open pilot trial with a small number of patients (n = 5, 65.4 yo + 9.71 years). The premise is that some retinal ganglion cells may survive within the damaged retinal area, but their innervations within the brain have been attenuated. VRT has been previously used in brain damaged individuals with several studies showing improved visual field results.^2,3 All individuals were diagnosed with primary open-angle glaucoma and had reproducible visual field loss. Visual fields were assessed using white on white and blue/yellow perimetry, performed with the Oculus Twinfield perimeter along with high resolution perimetry. Six visual fields were performed over a 6-10-week period to establish a stable baseline as well as determine the areas of residual vision, which were used in the training phase. Perimetry was then performed at 3, 6 and at 9 months. The computer-based vision restoration training is a neuropsychological method that has been described previously.² The principle is that areas of residual vision are stimulated with a white light on a grey background; allowing for a plasticity of the visual system to develop. The patient responds when they observe stimuli, similar to performing a field test. The training was done in two three-month sessions, with a three-month break in between. Two of the four individuals showed significant change, two showed mild change and one showed little change. The changes were most noticeable after the first training phase, and the results were quantified as an increase in stimuli observed. Blue-on-yellow perimetry did not reveal any changes, but there was approximately a 12% increase in stimuli observed with the other methods. This novel study points to a possible modality to improve our patients' visual field loss. Further study is needed to understand the extent of the reversal and which individuals are most conducive to this therapy.

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