Visual field loss in primary congenital glaucomaGautam Sinha, MD, Bharat Patil, MD, Ramanjit Sihota, MD, FRCS, Viney Gupta, MD,Bhagabat Nayak, MD, Reetika Sharma, MD, Ajay Sharma, BSc, and Neeraj Gupta, BSc

PURPOSE To assess the visual field defects in primary congenital glaucoma (PCG) and to identify

Author affiliations: Glaucoma RCentre for Ophthalmic Sciences,Submitted April 7, 2014.Revision accepted December 2Correspondence: Prof Ramanj

Research Facility & Clinical ServAll India Institute of Medical SciCopyright � 2015 by the Am

Strabismus.1091-8531/$36.00http://dx.doi.org/10.1016/j.ja

124

associated risk factors.

METHODS In this cross-sectional study visual fields of consecutive PCG patients were examined using

Humphery Field Analyzer (HFA) or Goldmann visual field (GVF). All patients had main-tained an intraocular pressure (IOP)#14 mmHg on standard care. Mean deviation, patternstandard deviation (PSD), foveal threshold inHFA, and global visual field extent (degrees) in24 meridians for targets V4e, I4e, I2e in GVF were recorded and evaluated with respect tobaseline IOP and age at detection. Statistical analysis was performed by Kruskal Wallis andMann-Whitney test. Qualitative analysis of GVF and reliable fields in HFA was performed.

RESULTS A total of 100 eyes of 77 patients were included: 56 eyes of 47 patients were in the HFA

group; 44 eyes of 30 patients, in the GVF group. On HFA, mean deviation detected at#1 month of age was significantly lower than eyes detected after 1 year (P\ 0.001). OnGVF, the global visual field extent for target I4e and I2e was significantly lower for PCG de-tected at#1month of age compared to those seen at.1 year (I4e,P\0.001; I2e,P5 0.005).Mean deviation, PSD, and foveal threshold were significantly lower in PCG with baselineIOP of .30 mm Hg than with IOP of 20–25 mm Hg (mean deviation, P\ 0.001; PSD,P5 0.002; foveal threshold, P5 0.002). Extent for targets V4e and I4e on GVF were signif-icantly lower in patients with baseline IOP of.30 mmHg compared to those with baselineIOP of 20–25 mm Hg (V4e, P 5 0.002; I4e, P 5 0.003). Definitive glaucomatous defectswere found in 36 eyes (41%), most ommon being arcuate scotoma (19 eyes [22%]).

CONCLUSIONS PCG detected at age #1 month and those having a baseline IOP of .30 mm Hg show

greater visual field loss. ( J AAPOS 2015;19:124-129)

Primary congenital glaucoma (PCG), a major causeof blindness in children,1 manifests at birth or inearly childhood with corneal enlargement, corneal

Subjects and Methods

This cross-sectional study of consecutive patients with PCG

treated at Dr Rajendra Prasad Centre for Ophthalmic Sciences,

opacification, photophobia, and tearing. Medical manage-ment can be used as a temporarizing measure or adjuvanttherapy, but surgery is generally required. Most studieson congenital glaucoma have reported intraocular pressure(IOP) over time and, less frequently, visual acuity. Thereare limited reports of perimetry in PCG,2-8 even thoughvisual field loss may adversely affect a child’s ability tofunction, and his or her quality of life. The purpose ofthe current study was to evaluate perimetry in a cohort ofpatients with PCG having a controlled IOP of #14 mmHg to determine the kind of defects seen in congenitalglaucoma and, secondarily, to correlate their severitywith clinical risk factors.

esearch Facility & Clinical Services, Dr Rajendra PrasadAll India Institute of Medical Sciences, New Delhi, India

6, 2014.it Sihota, MD, FRCS, FRCOphth, Head, Glaucomaices, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,ences, New Delhi -110029 (email: rjsihota@hotmail.com).erican Association for Pediatric Ophthalmology and

apos.2014.12.008

All India Institute of Medical Sciences on prospective, standard

of care review, was undertaken over a 1-year period from 2013

to 2014. Only cooperative children .5 years of age with

continuously controlled IOP (# 14 mm Hg) after management

by trabeculectomy with trabeculotomy augmented by mito-

mycin C, followed by use of antiglaucoma medications if

necessary, and having a best-corrected visual acuity (Snellen)

better than 6/60 were included. Exclusion criteria were the

presence of any other ocular anomaly, corneal pathology,

congenital cataract, uveitis, retinal disease, nystagmus, a rela-

tive afferent pupillary defect or the absence of vision on exam-

ination. The study was approved by the All India Institute of

Medical Sciences Ethics Committee and adhered to the tenets

of the Declaration of Helsinki. A written, informed consent

was taken from participants above 18 years of age or from par-

ents if the child was \18 years of age.

Age-matched controls were examined to validate the reliability

of perimetry and to obtain normative data. Controls were consec-

utive patients with strabismus but no significant refractive error,

amblyopia, or ocular pathology seen within the study period.

All patients received comprehensive examinations, including

slit-lamp biomicroscopy, applanation tonometry, fundus exami-

nation with 90 D lens, pachymetry, and cycloplegic refraction.

Journal of AAPOS

FIG 1. Goldmannvisualfield (GVF)of a control showingnormal visual field.The global visual field extent for a given target wasmeasured by adding thevalue in eachof 24meridians (15� apart). Extent for targetsV4e, I4e, and I2ein this figure are approximately 1515�, 1390�, and 755�, respectively.

Volume 19 Number 2 / April 2015 Sinha et al 125

Perimetry was performed with a Humphrey Field Analyzer

(HFA; Model 750; Carl Zeiss Meditec, Jena, Germany) using

the strategy 30-2 SITA Standard, when best-corrected visual

acuity was . 6/18. In eyes with a best-corrected visual acuity

of 6/60 to 6/24, or if automated perimetry could not be per-

formed reliably on two occasions in children having best-

corrected visual acuity of $6/18, kinetic perimetry was tested

with a Goldmann perimeter (Haag-Streit model 940-K7, Bern,

Switzerland). Patients were perimetrically experienced, and at

least one practice trial was administered before testing began.

At least 2 reproducible fields had to be present for analysis,

and the interval between them ranged from 1 to 6 weeks. All chil-

dren were tested with best-corrected refractive corrections, both

for HFA and GVF.

On HFA, a standard size III stimulus with background illumi-

nation of 31.5 apostilb was used. Only reliable and reproducible

fields were taken for qualitative and quantitative assessment. Fix-

ation losses of .20% and false positives or negatives of .33%

were taken as unreliable. Reliable fields were classified as, normal,

or having visual field defects using Hodapp-Parrish-Anderson

classification9 (e-Supplement 1, available at jaapos.org).

On Goldmann perimetry, the eye with better vision was tested

first to familiarize the patient with the test. Patients were instructed

to maintain fixation on the central fixation circle; the kinetic stim-

ulus was presented from the periphery toward the center at a speed

of 3-5 degrees per second. The point where the target was first seen

was noted as the visual field extent, and this was measured along 24

different meridians separated by 15� for targets V4e, I4e, and I2e

(Figure 1). The global visual field extent for a given stimulus was

determined by adding the extent in degrees for all 24 merid-

ians.3,10,11 Localized visual field defects were determined by static

presentation of smaller and less intense targets that the patient

was able to see within the central 15� along the 24 meridians.

The mean deviation, pattern standard deviation (PSD), and

foveal threshold in Humphery visual fields, and global visual field

extent in 24 meridians for targets V4e, I4e, and I2e for Goldmann

visual fields perimetry were recorded.

Records of patient were reviewed for age at detection of PCG

and baseline IOP before therapy. Age of detection was deter-

mined from referral papers and from parents regarding the first

appearance of signs and symptoms of the disease. Current cup/

disk ratio was determined by clinical examination by a single glau-

coma specialist (RS). Perimetry was then correlated with arbitrary

cutoffs—baseline IOP (20–25, 26–30, and .30 mm Hg), age at

detection (#1 month, .1 month to #1year, and .1 year), and

current vertical cup/disk ratio (#0.6, .0.6 to # 0.8, .0.8).

Because all patients were.5 years of age at the time of perime-

try, IOP was assessed by applanation tonometry at a slit-lamp on

at least 3 occasions without anesthesia. On prior occasions when

younger, IOP was measured by Perkin’s tonometer under a stan-

dard protocol using sevoflurane, without any muscle relaxant, and

laryngeal mask airway.

SPSS software (version 10.0, SPSS Inc, Chicago, IL) was used

for statistical analysis. Kruskal Wallis test was used to compare

three groups followed by multiple comparisons with Mann-

Whitney test with Bonferroni correction. For the Kruskal Wallis

test a P value of\0.05 was taken as statistically significant, and for

Journal of AAPOS

multiple comparisons a P value of\0.017 was considered statisti-

cally significant.

Qualitative analysis of GVF and reliable and reproducible

visual fields of HFA was performed to detect different patterns

of visual field loss for both HFA and GVF perimetry.12,13 Both

qualitative and quantitative analysis of all the visual fields was

performed by a single experienced glaucoma specialist (GS).

Results

HFA was performed on 56 PCG eyes of 47 children; Gold-mann perimetry, on 44 PCG eyes of 30 children. Of the 47examined by HFA, 27 had bilateral glaucoma; 20, unilat-eral. Eighteen eyes did not meet inclusion criteria. Amongpatients who underwent GVF, 19 had bilateral glaucomaand 11 had unilateral glaucoma; 5 eyes were not included.

All patients were followed regularly during the studyperiod, with IOP measurement while sleeping or undergeneral anesthesia; none of the eyes in our study had anIOP of.14 mmHg for more than 6 weeks after the initialsurgery. If IOP was not controlled on medications, repeatsurgery (trabeculotomy with trabeculectomy augmentedby mitomycin C) was performed. Only 6 eyes requiredrepeat surgery, 2 patients with age of detection of #1month of age, 1 with age of detection of .1 month ofage to 1year, and 3 with age of detection of .1 year. In 4patients PCG was detected after 4 years of age and age atsurgery was 4-5 years; for these patients perimetry was per-formed at least 1 year after the initial surgery.

Mean spherical equivalent refractive error for eyesincluded in the study was –4.2 � 3.2 D (median, �3.12D; range, �1.50 to �7.00 D). Mean interocular differencein refractive error was 1.8 � 1.2 D (median, 1.25 D; range,0.00-3.00 D) in bilateral cases and 4.5 � 2.7 D (median,4.62 D; range, 1.00-6.5 D) in unilateral cases.

Table 1. Analysis of perimetric parameters with age at detection

Test parameters Group A #1 monthGroup B .1

month to #1 year Group C .1 year Kruskal-Wallis

Mann-Whitney intergroupcomparison, P value

A vs B B vs C A vs C

Goldmann visual field, median values (range)

(n 5 10) (n 5 19) (n 5 15)

Extent for targets, degV4e 1083.5 (856-1566) 1362 (1042-1582) 1327 (1032-1554) 0.084 — — —I4e 411.5 (258-1025) 852 (400-1361) 1083.50 (856-1566) 0.0001 0.001 0.033 \0.001I2e 165 (96-204) 381 (104-498) 341 (99-743) \0.001 0.002 0.544 0.005

Humphery visual field, median values (range)

(n 5 12) (n 5 18) (n 5 14)

MD, dB 17.01 (7.33-30.32) 10.21 (2.41-28.41) 9.69 (1.54-29.61) 0.001 0.006 0.102 \0.001PSD, dB 8.10 (4.21-10.64) 5.39 (1.90-10.92) 6.29 (1.94-9.31) 0.022 0.086 0.166 0.008Foveal threshold, dB 26 (20-32) 30 (22-34) 28.50 (22-34) 0.028 0.024 0.602 0.0169

MD, mean deviation; PSD, pattern standard deviation.

Table 2. Analysis of perimetric parameters with baseline IOP

Test parametersGroup A baselineIOP\25 mm Hg

Group B baselineIOP 25–30 mm Hg

Group C baselineIOP .30 mm Hg Kruskal-Wallis

Mann-Whitney intergroupcomparison, P value

A vs B B vs C A vs C

Goldmann visual field, median values (range)

(n 5 15) (n 5 13) (n 5 16)

Extent for targets, degV4e 1479 (1191-1598) 1354 (845-1521) 1205 (569-1497) 0.004 0.76 0.56 0.002I4e 843 (341-1361) 525 (239-1258) 415.50 (126-981) 0.008 0.50 0.196 0.003I2e 391 (209-840) 247.00 (113-841) 266 (87-621) 0.305 — — —

Humphery visual field, median values (range)

(n 5 20) (n 5 14) (n 5 10)

MD, dB �4.35 (1.54-17.70) �10.49 (3.21-30.32) �16.56 (5.87-33.41) \0.001 \0.001 0.009 \0.001PSD, dB 1.61 (1.12-6.34) 7.12 (1.78-9.84) 8.57 (3.32-12.89) \0.001 \0.001 0.044 0.002Foveal threshold, dB 30 (26-34) 29 (22-34) 27.50 (20-32) 0.001 0.054 0.044 0.002

IOP, intraocular pressure; MD, mean deviation; PSD, pattern standard deviation.

126 Sinha et al Volume 19 Number 2 / April 2015

Themean age of patients with PCGwho underwentHFAexamination was12.2� 3.6 years (median, 12.50 years; range5-21 years). Thirty-three patients (70%) were male. Therewere 44 reliable visual fields (79%); 12 (21%,) were unreli-able. Themost common cause of unreliability in our patientswas a high false positive response in 9 eyes (75%), followedbya high loss of fixation in 3 eyes (25%). Of the 44 reliable andreproducible fields, 12 (27%) were within normal limit and32 (73%) had a visual field defect. Eleven eyes (25%) hadmild visual field defect, 12 (27%) had moderate visual fielddefect, and 9 (20%)had severe visual field defect. The controlgroup consisted of 12 eyes of 12 patients (mean age, 11.92�3.27 years; range, 6-19 years).ThemeandeviationonHFA inpatients with PCG classified as having a normal visual fieldwas�2.92� 1.19 dB, similar to themeandeviation in controleyes of�2.52� 0.91dB (P5 0.338). The mean PSD in eyeswithPCGclassified ashaving a normal visual fieldwas 1.35�0.28 dB, similar to mean PSD in control eyes of 1.31�

0.35dB, P5 0.768. The mean deviation in eyes with mild vi-sual field loss was �5.05 � 0.80 dB; with moderate loss,�10.49 � 1.33 dB; and with severe loss, �15.91 � 4.24 dB.The mean PSD in eyes having mild loss was 1.64 � 0.24dB; moderate loss, 4.36 � 2.62 dB; and severe loss, 5.37 �3.21 dB. The mean foveal threshold in eyes having a mildloss was 30.28 � 3.03 dB; moderate loss, 28.41 � 3.85 dB;and severe loss, 25.52 � 4.45 dB.

The mean age of patients undergoing Goldmann peri-metry was 11.6 � 4.8 years (median, 11.50 years; range,5-19 years). Twenty-three patients (77%) were male. Theage-matched control group consisted of 17 eyes of 17 pa-tients aged 5-17 years (mean, 11.3 � 4.9 years).

The mean global visual field extents in controls for targetV4e, I4e, and I2e were 1538.6� � 101.5�, 1317.5� � 98.5�,and 801.6� � 121.2�, respectively, which was significantlyhigher for all three targets compared with PCG patients(P\0.001 for all three targets). Themean global visual field

Journal of AAPOS

Table 3. Analysis of perimetric parameters with present cup/disk ratio

Test parametersGroup A cup/disk

ratio #0.6Group B cup/diskratio 0.6 to #0.8

Group C cup/diskratio .0.8

Kruskal-Wallis

Mann-Whitney intergroupcomparison, P value

A vs B B vs C A vs C

Goldmann visual field, median values (range)

(n 5 16) (n 5 15) (n 5 13)

Extent for targets, degV4e 1495 (1191-1598) 1305 (569-1521) 957 (700-1318) \0.001 0.004 0.007 \0.001I4e 1213 (675-1361) 545 (126-981) 341 (225-493) \0.001 \0.001 0.14 \0.001I2e 448 (267-575) 267 (87-567) 198 (113-341) 0.001 0.001 0.062 \0.001

Humphery visual field, median values (range)

(n 5 20) (n 5 14) (n 5 10)

MD, dB �17.01 (�1.54 to �17.7) �8.21 (�3.67 to �19.92) �17.56 (�13.40 to �33.41) \0.001 0.001 0.003 \0.001PSD, dB 1.93 (1.12-8.21) 7.56 (1.38-9.31) 9.32 (4.21-12.89) 0.001 0.234 0.002 0.001Foveal threshold, dB 32 (24-34) 30 (24-32) 25.5 (22-30) \0.001 0.001 0.014 \0.001

MD, mean deviation; PSD, pattern standard deviation.

FIG 2. HVF 30-2 SITA standard of a PCG patient showing superiorarcuate scotoma.

Volume 19 Number 2 / April 2015 Sinha et al 127

extents in the normal fields (7 eyes) of PCG patients for tar-gets V4e, I4e, and I2e were 1446.6� � 141.2�, 1198.1� �278.6�, and 748.1� �178.6� (P 5 0.085, 0.128 and 0.401,resp.). The mean global visual field extents in patients withPCG for target V4e, I4e, and I2e were 1198.6� � 186.5�,742.8� � 279.5�, and 431.6� � 164.2�, respectively.Tables 1, 2, and 3 show quantitative analysis of both

HFA and GVF with respect to age at detection, baselineIOP, and present vertical cup/disk ratio, respectively,along with statistical comparison.On qualitative analysis of reliable visual fields in

Humphery perimetry,11 the glaucoma hemifield test(GHT) was within normal limits in all eyes having a normalvisual field and was out of normal limits in all eyes with se-

Journal of AAPOS

vere visual field defect. In eyes with moderate visual fielddefect the GHT was borderline (n 5 2), outside normallimits (n 5 8), or showed a generalized loss of sensitivity(n 5 2). In eyes with mild visual field defect GHT wasnormal (n 5 1), borderline (n 5 3), outside normal limits(n 5 3), or showed a generalized loss of sensitivity (n 5 4).

On qualitative analysis of Goldmann perimetry,12 7 of 44eyes (16%) had normal visual fields for all 3 stimulus sizes,15 (34%) had a generalized depression, 4 (9%) had a focaldepression, 2 (5%) had baring of the blind spot, 2 (5%) hadonly a central island, 8 (18%), had concentric (generalized)constriction, and 6 (14%) had focal constriction.

Overall, in 88 eyes (considering only reliable fields onHFA), a definitive scotoma was present in 36 eyes (41%[28HFA; 8GVF]). In 12 eyes (14% [8HFA; 4 GVF]) therewas a single arcuate scotoma (Figure 2); in 7 (8% [4HFA; 3GVF]), biarcuate scotoma; in 8 eyes (9% [7 HFA; 1 GVF]),paracentral scotoma; in 5 eyes (6% [all HFA]), nasal step;and in 4 eyes (5% [all HFA]), only a central island of vision.

With respect to the location of definitive scotomas, in 11eyes (36%) both hemispheres were affected, scotomas werebiarcuate, and there was a central island of vision; in 17 eyes(47%) there was a superior scotoma; in 8 eyes (22%) onlythe inferior hemisphere was affected.

Discussion

Studies of PCG have commonly focused on surgicalmanagement, complications, and factors affecting surgicalsuccess.14-17 However, successful surgical treatment doesnot necessarily lead to good functional outcomes in terms ofvisual acuity.18,19 There are a limited number of studies thatreport on perimetry in PCG.2-8 Visual field assessment is animportant component of overall visual function in PCG.The current study was undertaken to evaluate perimetry ina cohort of primary congenital glaucoma patients having acontinuously controlled IOP of #14 mm Hg after thesurgery and to determine risk factors for the same.

Table 4. Previous perimetric studies in congenital glaucoma and comparison with our study

Perimeter used No eyesIOP control,mm Hg

Eyes withabnormalfield, n (%)

Eyes withlocalized definitivescotomas, n (%)

Mostcommon

scotoma (%)Field moredamaged

Robin et al (1979)4 Goldmann 74 NA 49 (66.21) NA Arcuate (39) SuperiorMorin et al (1980)6 Goldmann and automated 89 8-24 NA NA NA NARolando et al (1985)5 Peritest and Perikon 53 NA 34 (64.15) NA Arcuate (47.1) NASampaolesi et al (1991)8 Octopus 2000 46 NA 38 (82.60) 3 (6.5) NA NASouza et al (2000)3 Goldmann 16 #21 NA 6 (37.5) Nasal step NALopes et al (2007)2 Humphery 66 NA 38 (57.57) 21 (31.8) Paracentral (47.6) InferiorCurrent study Goldmann and Humphery 88 #14 69 (78.40) 36 (40.7) Arcuate (53) (single

and biarcuate)Superior

128 Sinha et al Volume 19 Number 2 / April 2015

This study found abnormality on perimetry in 69 eyes of 88(78%). However, definitive scotomas were present in 41% ofeyes. A single arcuate scotoma was the most common defini-tive scotoma (14%), followed by paracentral (9%) and biarcu-ate scotoma (8%). On analyzing all definitive scotomasrestricted to one hemifield, the superior was more commonthan the inferior hemifield, but more than 50% showedinvolvement of the inferior field. Available literature on peri-metry in PCG is summarized in Table 4. Robin and col-leagues4 performed Goldmann perimetry in 74 eyes ofchildhood glaucomas of which 66% were abnormal. In theirstudy, arcuate scotomas were also most common (39%), andthe superior visual field had 43% more visual field defectsthan the inferior. Ronaldo and colleagues5 also found arcuatedefects to be most common (47%). Sampaolesi and col-leagues8 found abnormal visual fields in 83% of eyes (38/46);however, localized visual field defectswere found in only about7%. Souza and colleagues3 reported nasal step to be the mostcommon localized visual field defect in 50% of PCG eyes.Lopes and colleagues,2 in their study using HFA in 66 PCGeyes found 58%of visual fields to be abnormal, with and a par-acentral scotoma themost common localizedvisualfielddefect(48%) and inferior hemifield involvementmore common thansuperior.Most of these studies have notmentioned the IOP atwhich perimetry was performed, and adult IOP values of\21mmHghave often been used,whereas, pediatric IOPhas beenrecorded to be in the range of 10–14 mmHg.20,21

The current study shows that visual field defects in PCGare similar to those reported in adults by Sihota and col-leagues,12 who found the most common definitive scotomadetected on automated perimetry in glaucoma patients tobe a single arcuate scotoma (31%), followedbydouble arcuatescotomas (27%); paracentral scotomas were infrequent (1%).

Previous studies have shown that the prognosis for sur-gical success is lower in glaucoma presenting at an earlyage.14-16 Our study found that neonatal or birth-onsetPCG also leads to greater long-term perimetric damage,even if the IOP is well controlled to pediatric levels. Sam-paolesi and colleagues8 reported diffuse loss of sensitivityin 74% of children presenting at an early age (within thefirst 6 months); if IOP was normalized promptly, however,localized defect occurred in only about 11%.

A high baseline preoperative IOP has been linked withpoor prognosis for surgical outcomes in terms of IOP22;

however, its role as a prognostic factor for changes in visualfields has not been studied previously. The current studyfound that baseline IOP, especially of .30 mm Hg, wassignificantly associated with visual field loss. It also foundthat severity of field loss in bothHFAandGVFgroups couldbe directly correlated to current vertical cup/disk ratio.

In our study, mean global visual field extent in controlsfor target V4e, I4e, and I2e were significantly higher forall three compared with those of PCG patients. De Souzaand colleagues3 reported that monocular visual field totalextent for target I2e in congenital glaucoma eyes was statis-tically lower than controls; however, in their study theextent for target V4e and I4e were comparable for patientsand normal controls.

Assessing perimetry in children is difficult because of lackof familiarity with the task, relatively short attention span,and fatigue. However, studies23-25 have indicated thatreliable results can be obtained in children as young as 5years of age who have been familiarized with theprocedure. The most common cause of unreliability in ourstudy for HVF perimetry was excessive false positiveresponses and, less frequently, fixation losses. Previousstudies2,24 have shown fixation losses to be the mostcommon cause of unreliability in children duringautomated perimetry. Excessive false positive results can beattributed to the “trigger happy” nature of young children,who want to please the examiner and are happy to respond.

A strength of our study is that we assessed risk factorsassociated with severity of visual field loss in operated casesof PCG. We performed the qualitative as well as quantita-tive analysis of visual fields by manual kinetic perimetry aswell as automated perimetry in operated cases of PCG. Inour study congenital glaucoma detected in the first monthof life and eyes having a baseline IOP of.30 mmHg werefound to be a poor prognostic factor for visual field defects.

Previous studies have showed that monocular visual fieldsin amblyopic eyes on kinetic perimetry are not affected ifperformed with refractive correction,26 and on automatedperimetry it has been shown that all types of amblyopia areassociated with a generalized depression of the visual fields,with decreased foveal thresholds that correlates with visualacuity without any focal defects.27 Although the minimumrequired best-corrected visual acuity for HFA examinationin our study was 6/18, we could not assess the severity of

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Volume 19 Number 2 / April 2015 Sinha et al 129

amblyopia in PCG eyes because of additional corneal andoptic nerve changes. Agents used for general anesthesiahave been known to alter IOP; however, a previous studyhas shown that laryngeal mask airway does not increaseIOP in children after sevoflurane induction.28 The otherlimitations of our study were the small sample size and thelimited number of controls both for GVF and HFA exami-nation. Interpretation of HFA and GVF results together(for example, definitive scotomas)was alsonot ideal.Howev-er correlation of visual field defects on GVF and HVF inadults is well established and probably applies to childrenas well.29,30 Ideally, results obtained from two differenttypes of perimetric examination should not be interpretedin combination, and whenever possible HFA should bechosen over the Goldmann perimeter to document anddemonstrate progression of visual field defects.31

References

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2. Lopes Filho JG, Betinjane AJ, Carvalho CA. Automated perimetry in pa-tients with primary congenital glaucoma. ArqBrasOftalmol 2007;70:37-40.

3. De Souza EC, Berezovsky A, Morales PH, de ArrudaMello PA, de Oli-veira Bonomo PP, Salom~ao SR. Visual field defects in children withcongenital glaucoma. J Pediatr Ophthalmol Strabismus 2000;37:266-72.

4. Robin AL, Quigley HA, Pollack IP, Maumenee AE, Maumenee IH.An analysis of visual acuity, visual fields, and disk cupping in child-hood glaucoma. Am J Ophthalmol 1979;88:847-58.

5. RolandoM, Capris P, Gandolfo E. In: . Dordrecht: DrW. Junk Pub-lishers; 1985:65-8.

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8. Sampolesi R, Casiraghi JF. Computerized visual fields in Pediatricglaucoma. In: Mills RP, Hejil A, eds. Perimetry Update 1990/1991.Amsterdam: Kugler and Ghedini; 1991:455-64.

9. Hodapp E, Parrish RK II, Anderson DR. Clinical decisions in glau-coma. St Louis: CV Mosby Co; 1993:52-61.

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12. Sihota R, Gupta V, Tuli D, Sharma A, Sony P, Srinivasan G. Classi-fying patterns of localized glaucomatous visual field defects on auto-mated perimetry. J Glaucoma 2007;16:146-52.

13. Alward WLM. In: Glaucoma: The Requisites. St. Louis: Mosby Inc;2000:56-102.

14. Dietlein TS, Jacobi PC, Krieglstein GK. Prognosis of primary ab ex-terno surgery for primary congenital glaucoma. Br J Ophthalmol1999;83:317-22.

15. Detry-MorelM, FeronEM.Trabeculectomy in congenital glaucoma:retrospective medium and long term results. Bull Soc Belge Ophtal-mol 1996;262:143-51.

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First Person

Beware other siblings in the room! I was once putting eyedrops in a 2-year-old, who startedto cry, as usual, when his older brother approached me slowly and kicked my leg!

Contributed by Samir B. El-Mulki, MD, Amman, Jordan