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.