VISUAL FIELD PATTERNS IN GLAUCOMA: A SYSTEMIC REVIEW

INTRODUCTION:

Retinal nerve fiber bundles are arranged in a specific distribution. As the greater part is located in the central 30° area, most early glaucomatous visual field defects (VFDs) are detected within this region. 

Typical glaucomatous visual field patterns include nasal step, paracentral scotoma, arcuate-like defects, diffuse loss, and altitudinal defects. 

Footnote: The blind spot is located at 15° temporally, where the optic nerve leaves the eye.

PRIMARY OPEN ANGLE GLAUCOMA (POAG):

The nasal step is described as the most frequent and earliest VFD, followed by paracentral scotomas and arcuate-like defects. 

The superior hemifield is more affected than the inferior hemifield.

Repeatable diffuse visual field loss was seen in 4.4% of patients, the only sign of early glaucomatous visual field loss. 

Diffuse visual field loss is nonspecific and can be caused by various other factors such as cataract, extreme miosis, and unreliable performance of the perimetry.

Early diffuse visual field loss usually converts into well-defined pattern defects at later stages. 

INFLUENCING FACTORS FOR VFDs IN POAG:

Initial VFDs located in the superior hemifield were associated with greater disc ovality (maximum diameter of an ellipse fitted to disc contour/minimum diameter of an ellipse fitted to disc contour), β-peripapillary atrophy and thinner central corneal thickness.

VFD in the inferior hemifield was more frequently found in both insulin-dependent as noninsulin-dependent diabetic patients (odds ratio [OR] =1.8).

The presence of systemic risk factors for glaucoma (especially NTG) such as hypotension, migraine, Raynaud’s phenomenon, and sleep apnea was significantly higher in POAG as well as NTG patients with an initial parafoveal scotoma than in patients with initial nasal step.

In NTG, these above-mentioned systemic risk factors for glaucoma were more prevalent in patients exhibiting initial central scotoma than in patients with initial peripheral scotoma. These findings suggest that systemic vascular risk factors in POAG and NTG patients are associated with central VFDs.

Body mass index and smoking (measured in pack-years) were more strongly associated with a lower risk of paracentral VFDs (HR [hazard ratio] Body mass index [BMI] =0.67; HR smoking = 0.92) than with peripheral VFDs (HR BMI = 0.93; HR smoking = 0.98). The relation between cigarette smoking and POAG overall has been conflicting. Nicotine has been mentioned to have a neuroprotective role. 

NORMAL TENSION GLAUCOMA:

NTG patients show more localized VFDs and are characterized by deeper, more central, and more depressed VFDs compared to POAG patients. 

PRIMARY ANGLE CLOSURE GLAUCOMA:

In early disease stages, the VFDs are most common in the nasal area.

Jiang et al. and Sim et al. observed that (partial) arcuate defects were the most common types of VFDs in PACG eyes. Atalay et al. showed that the superior hemifield was more impaired than the inferior hemifield across the whole severity spectrum. In contrast, Lau et al. found no significant difference in visual field loss between the superior and inferior hemifield.

Following an acute episode of angle-closure, a hemifield defect was the most common VFD.

PROGRESSION OF VFDs:

Primary-open angle glaucoma:

The most common pattern of progression is the deepening of an existing scotoma, followed by expansion, rather than the development of new scotomas, emphasizing the importance of reliable baseline VF testing.

With increasing severity, the VFD showed progression to the center and progression toward a connection with the blind spot.

The initial parafoveal scotoma showed a characteristic pattern of progression in a retrospective study conducted by Su et al. The parafoveal scotoma in the superior hemifield initially had an arcuate pattern that first deepened 3° to 5° above fixation, then elongated toward the physiologic blind spot, and spread towards the nasal periphery, sparing the area corresponding to the papillomacular bundle. The inferior parafoveal scotoma, showed similar characteristics, but tended to be further away from fixation. POAG patients progress faster in the superior hemifield defects compared to the inferior counterparts. This difference is more pronounced in the central, paracentral, and nasal area.

Patients with initial damage in both hemifields had higher chances of glaucomatous progression.

Normal-tension glaucoma:

NTG patients progress more often in the paracentral area. NTG patients with lower heart-rate variability had faster central visual field progression than those with higher heart-rate variability. Other vascular factors, such as migraine and orthostatic dysfunction were also related to increased central visual field progression.

REFERENCE:

Vandersnickt MF, van Eijgen J, Lemmens S, Stalmans I, Pinto LA, Vandewalle EM. Visual field patterns in glaucoma: A systematic review. Saudi J Ophthalmol. 2024 Dec 26;38(4):306-315. doi: 10.4103/sjopt.sjopt_143_24. Erratum in: Saudi J Ophthalmol. 2025 Oct 13;39(3):286. doi: 10.4103/sjopt.sjopt_374_25. PMID: 39943959; PMCID: PMC11811403.

SCHWARTZ-MATSUO SYNDROME

Introduction:

Schwartz-Matsuo syndrome is a rare condition characterized by the triad of rhegmatogenous retinal detachment (RRD) (usually with peripheral breaks or oral dialysis), elevated intraocular pressure (IOP) with marked fluctuation, and cells in the anterior chamber. In cases of retinal detachments not associated with Schwartz-Matsuo syndrome, there is usually low IOP secondary to increased outflow by active pumping of aqueous humor through the exposed retinal pigment epithelium. However, IOP in Schwartz-Matsuo syndrome is elevated.

The syndrome was first described by Schwartz in 1973. He described the classic findings of elevated IOP and apparent iridocyclitis associated with RRD and open AC angles. In 1986 Matsuo et al. discovered photoreceptor outer segments on electron microscopy of the aqueous humor and theorized that the free photoreceptor outer segments blocked the trabecular outflow leading to elevated IOP.

Electron microscopy of aqueous humor in such patients has demonstrated photoreceptors outer segments. The photoreceptor outer segments and/or retinal pigment epithelium (RPE) pigment pass through a retinal break, leading to outflow obstruction in the trabecular meshwork. 

The syndrome presents with, or mimics, severe open-angle glaucoma. It can be mistaken for uveitis or uveitic glaucoma, but it does not respond to corticosteroids. There are no features of inflammation such as pain, redness or ciliary flush.

Following retinal detachment repair, IOP typically normalizes and prognosis is favorable.

Symptoms:

Patients typically present with complaints of unilateral blurry vision, eye pain, and nausea associated with the elevated IOP, as well as floaters, photopsia, and scotoma secondary to the retinal detachment. 

Risk Factors:

Shallow RRD involving the vitreous base (a shallow detachment allows for constant sloughing of dying photoreceptor outer segments and involvement of the vitreous base allows for the photoreceptor outer segments to gain access to the anterior chamber. An intact hyaloid would not allow them to reach the anterior segment).

Other risk factors include:

• Retinal dialysis or retinal tears at the ora serrata. 
• History of ocular trauma or surgery.
• Myopia, or lattice degeneration.

Diagnosis:

On examination, IOP is elevated, with marked fluctuation in pressures. Pigmented aqueous cells are present in varying number, but there are usually no other signs of uveitis. On gonioscopy, the anterior chamber angles are typically open; however, angle recession may indicate prior ocular trauma. Finally, there is retinal detachment with tears most commonly located at the ora serrata or non-pigmented epithelium of the pars plana or pars plicata. The retinal detachment is often shallow and involves a wide area, including the macula.

Identification of photoreceptor outer segments in the aqueous humor by electron microscopy assists in the diagnosis. OCT will demonstrate the presence of subretinal fluid indicative of retinal detachment.

Systemic examination (Marfan's syndrome or atopic dermatitis may help identify patients who are at risk of a retinal break around the ora serrata).

Routine assessment of the visual acuity and monitoring of IOP should be done.

Gonioscopy will show an open angle and can rule out other etiologies of increased IOP: angle recession, angle closure, peripheral anterior synechiae, neovascularization, and others.

Differential diagnosis:

1. Iritis: The anterior chamber findings in Schwartz-Matsuo syndrome are not inflammatory. The presence of anterior synechiae and keratic precipitates indicates an inflammatory condition which would rule out this condition. It should also be noted that the aqueous cells in Schwartz-Matsuo syndrome are unresponsive to corticosteroid treatment.
2. Open-angle or other secondary glaucomas should be considered, especially if it occurs in a patient with a history of blunt trauma.
3. Posner-Schlossman syndrome shows very mild anterior chamber inflammation with few cells and little flare, few fine keratic precipitates, and responds to steroid treatment.

Management:

Schwartz-Matsuo syndrome should be managed as a secondary cause of glaucoma, with first line treatment including repair of the retinal detachment and washout of the AC cellular debris. Typically, IOP returns to normal following retinal detachment repair. 

Immediate glaucoma management includes maximizing medical therapy before retinal surgery with oral carbonic anhydrase inhibitors with or without pilocarpine. Pilocarpine may help to open the trabecular meshwork pores but is associated with miosis and increased risk of retinal detachments.

Similar to the treatment of pigmented cells seen in pigment dispersion syndrome, laser trabeculoplasty should lower the IOP, but may not achieve satisfactory results. Additionally, laser trabeculoplasty may place patients at higher risk for post-operative IOP spikes given their compromised trabecular function. 

A tube shunt is preferred over trabeculectomy given the possible conjunctival scaring following retinal surgery and the risk of hypotony maculopathy with the use of antifibrotic agents in young, highly myopic patients. Tube shunts may induce diplopia via restrictive strabismus when combined with sclera buckle. An additional consideration is the timing of the tube shunt implantation, whether at the time of retinal surgery or not.

Prognosis:

Is usually good, with IOP returning to normal following successful RRD surgery.

HIGH PILLOW POSITION & IOP

Intraocular pressure (IOP) fluctuates significantly in response to body position. The IOP is lowest in the sitting posture and increases in the order of supine and lateral decubitus positions.

These changes are attributed to the increase in episcleral venous pressure and choroidal vascular volume. The uveal tissues also develop congestion and expansion from increased venous and arterial pressures in the orbit, contributing to the increased IOP.

Therefore, postural modification may serve as a potential adjunctive strategy for IOP management in glaucoma patients.

In a study by Liu et al, involving 144 glaucoma patients, IOP was measured and compared between the high-pillow position (head elevated by 20–35° using two pillows) and the supine position. Additionally, changes in jugular venous lumen in response to postural variation were evaluated via ultrasonography in 20 healthy volunteers.

The authors reported that, compared with the supine position, the high-pillow position was associated with significantly elevated IOP, increased 24-hour IOP fluctuation and reduced ocular perfusion pressure (OPP) (all p<0.001). 

Greater postural IOP fluctuation (ΔIOP) was observed in younger individuals (p=0.027) and patients with primary open-angle glaucoma (POAG) (p<0.001). 

Multiple regression analysis identified thicker central corneal thickness and the presence of POAG (vs normal-tension glaucoma) as positive predictors of larger ΔIOP changes (both p<0.05). 

Ultrasonography in healthy volunteers revealed significant constriction of both internal and external jugular venous lumen in the high-pillow position (all p<0.001), accompanied by an increase in maximum blood flow velocity of the internal jugular vein (p=0.013).

Therefore, compared with the supine position, the high-pillow position is associated with increased IOP and decreased OPP in patients with glaucoma, which may be linked to jugular venous compression. 

ADVICE: 

Patients with glaucoma may benefit from avoiding sleeping postures that induce jugular venous compression to mitigate postural IOP elevation.

REFERENCE:

Liu T, Hu M, Liu X, et al. Association of high-pillow sleeping posture with intraocular pressure in patients with glaucoma. British Journal of Ophthalmology. Published Online First: 27 January 2026. doi: 10.1136/bjo-2025-328037.