The Open Perimetry Interface (OPI):

Glasnost and Perestroika in the Visual Field

Andrew Turpin, Melbourne Paul Artes, Halifax North American Perimetric Society (NAPS), New York, 2011

In 1986, the Soviet Union was facing economic, social, and moral ruin. Michael Gorbatchov came along and proposed glasnost - openness, transparency perestroika - rebuilding, reconstruction

By 2010, perimetry has seriously fallen behind imaging in terms of innovation and excitement. There has been no major innovation since SITA(1997). The eld is isolated from mainstream science (physics, psychology, medicine) Commercial players do their own thing. Clinicians and scientists work largely within their own groups using laboratory equipment. A vast resource of creativity lies unharnessed and frustrated. It feels very different from Tbingen in 1986...

We need to: Creatively seek new ways to examine visual elds. The center as well as the periphery With static as well as kinetic stimuli With threshold as well as suprathreshold strategies With spots as well as with new types of stimuli Efciently collaborate with each other, and with industry. Quickly translate new ideas into experiments. Quickly translate experiments into clinical tools.

Many current problems of perimetry have long been addressed in other disciplines. Perimetry is at least two to three decades behind the state-of-the-art. Many talented scientists would like to work on clinically relevant problems, but lack the tools. Industry makes beautiful hardware, but this is inaccessible for basic experiments. Accessing clinical data is often like breaking into the Pentagon. There are laudable exceptions.

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36 to 86 years). The normal to be used as anrecruited meavisual field defects, and no other apparent mechanism If reaction time is subjects were outcome fifth presentation thereafter. Numerically, the rate of for from a sure in of subjects undergoing other psycho- relagroup conventional automated perimetry, the of glaucoma. All patients were receiving treatment fixation losses was pressure control, but none were using a physicaltionship of RT to threshold must normal visual there studies. All normal subjects had be defined. If intraocular the percentage of blind spot presenfields defined by relationship between reaction the and miotic. Patients with primary the angle glaucoma is a constant the Statpac program of time tations reported by the subject over opentotal number of Humphrey Field in health and disease, one would hope this blind spot presentations.had any other disease known to were excluded if they threshold Analyzer (Humphrey Instruments, 7 San Leandro, CA) couldabe used to familypredict threshold relationship and negative help history of Data cause visual loss. All subjects had corrected visual acuAnalysis ity of 20/25 or better, pupil diameter of at least 3 mm glaucoma. aThe patients with suspected glaucoma and was in more accurate and less variable way. Our goal The when tested, spectacle correction not exceeding those with glaucoma were recruited reaction time to the frequency-of-seeing at each stimulus intensity was 6.00 to determine this relationship of consecutively computed. These data were subjected to a probit analy-with D (equivalent sphere), and previous experience from the clinical practice of one normal subjects, normal senpsychometric function in of us (RPL). Patients sis, which fitted perimetric examinations. automated a frequency-of-seeing curve to the with suspectedtest locations in normal visual glaucoma, and sitivity glaucoma had patients with fields as defined test locations with 10 to 20 these patients had with above; however, 10 of 12 of dB loss in patients data. The threshold was taken as the stimulus intensity Testing to the 50% frequency-of-seeing of the corresponding Strategy consistently increasedwell as to investigate the 22 mm glaucoma, as intraocular pressures (> relationship fitted curve. The threshold deviation was computed by perConventional automated perimetry was first Hg), whereas the by Flammer2and coworkers9 of adisks suggested remaining had suspect optic prolonged subtracting the threshold from the program 24-2 using the formed with the HVFA with age-corrected noron the grounds of asymmetry with the fellow eye.in subjects RT associated with an increase in threshold Pamal value for that specific location. The(exceptof the manufacturer's recommendations slope for three tients with glaucoma had glaucomatous visual fields with glaucoma. curve subjects in whom calculating30-2 was performed). was estimated by program the interquartile (with early to advanced damage) and optic disks. All range These programs test the centralcorresponding to (stimulus intensity interval 21 or 27 of the visual subjects had an ophthalmic examination, visual acuity 25% to 75% frequency-of-seeing)apart; in fitted curve. 24field with stimuli spaced 6 of the addition, the METHODS of 6/9 or better, previous experience with perimetric 2 program tests one stimulus above and one stimulus Figure 1 shows an example of a frequency-of-seeing examinations, pupil diameter of at least 3 mm when Subjects curve belowthe calculated parameters. We used a Goldwith the nasal horizontal at 27. tested, and a spectacle correction not exceeding 4.00 mann size between 2) object on a 31.5-asb backTen patients sphere). The study was approved angle Correlations III (4 mmvariables were examined primary open diopters (equivalent with well-establishedCurves in Normal The Psychometric Function and Reaction Times of Characteristics of Frequency-of-Seeing ground. The correlation. Differences between with Automated Perimetry in stimulus was fixed, and the by the glaucoma and 10 normal volunteers gave informed the Spearman size of the Normal and Abnormal Areas of Camp Hill Medical Centre Research Subjects, Patients With Suspected Glaucoma, Ethics threshold to differential determined was consent to participate in the study. The protocol correlation coefficients were light intensitywith estimated Committee and followed the tenets of the Declaration was the Visual Field in Patients With Glaucoma stanand Patients With Glaucoma approved by consent was of Iowa Institutional dard at each test point with a staircase used to anaof Helsinki. Informedthe Universityobtained from each Re- tests.10 An analysis of covariance was procedure. Each Balwantray C. Chauhan* James D. Tompkins,-\ the Declaration patient's RichardJ. Maw* Kim the and was used. lyze Michael Wall,*data. Residuals ofStanek* regressions be- Rest subject. view Board. The tenets ofRaymond P. LeBlanc* of Helsinki the pooled appropriate nearE.correctionBalwantray C. Chauhanf and Terry A. McCormick* were followed. The normals were paid volunteers who tween breaks were givenvariables and covariates were the dependent when requested. Purpose. To of relationship of reaction time to the psychometric were hospital employees or friends or family members Frequency study thehomoscedasticity.measured by in normal tested for normality andseeing curves were glaucoma, and testfunction consubjects, normal sensitivity test locations in patients with Where nec- with 10 locations Purpose. The authors characteristics Testing frequency-of-seeing performednormal subjects, Thefactorssuspected glaucoma, and pa- were Methodscurves in this study to determine with that affect thesubjects of eye clinic patients. patients normal tothe HVFA with glaucoma. 20 dB of essary,trolling Methods.loss inauthors tested 10performed. program run by a log transformspatientswith patients with glaucoma and 10 age-matched normal volunteers were a custom All statistical tients with glaucoma. The matched pairwise to patients by age withinex- years. were twowithcomputer statistical Packard then withwas setofCA] 5 Alto, the Humphrey perimeter, first with significance the method constant tests personaltailed, and (Hewlettprogram 24-2 and [Palo visual field locations The Humphrey Field Analyzer can subjects, 12 patients with suspected Methods. The sample consisted of 70 subjects (22 normal be controlled3535 stimuli to generate frequency of seeing curves. At two widely separated Normals were includedA program was written tono history of eye if they had with Vectra 486, 33 mHz). At twostimuli in 2-dB intervals, 10 dB side of the different test locations, ternally glaucoma, and 36 patients withcomputer San Leandro, CA) toainterfacefrequencyby a personal glaucoma). series the of at P< 0.05. on the program 24-2 grid,atthey presenteddB (15 repetitions per intensity).eitherthe patients Humphrey Field Analyzer (Humphrey Instruments, through measure program 24-2 threshold, 0 dB and 60 disease except presented stimuli 8 dB either sideand estimated threshold in refractive error of the normal results of stimuli with glaucoma, they chose a visualin 2-dBwith normal sensitivity and For and were presented field location intervals up ato in an of-seeing curves. The authors location commands. We have written stimulus intensity. The authors tested four that au1-dB intervals with five repetitions at each a computer program to six area of10to dB loss. ophthalmologicrandomization of the stimulusThey and location. Fixation examination. intensity all had normal including 10 20 dB from either side of the estimated locations in each subject, with Analysis variance uses these commands andmethod. Using using the the authors calculated Visual was monitored with the Heijl-Krakau allowsa us to conduct many tomated slope (estimated by results probit program, Humphrey (HVFA Results. was prolonged by approximately 90<-tests showedabnormal sensitivity (RT)location0-dB program of24-2)with post hoc msec in with reactionrepetitionsof threshold, the that 15 time test at the intensity the threshold and perimetry the interquartile range) of each curve. patients with glaucoma compared the glaucoma normal customized TheAnalyzer 124 curves from the normal subjects, 71 from the patients with San including the measurement of freResults. authors Fieldtests, obtained (HVFA; Humphrey Instruments, at each stimulus intensity.toAllcontrol and thefor by only 4 of thestimulus presentations of sensitivity groups (P < 0.0001). However, this difference was accounted 10 patients with suspected glaucoma, and 183 from the patients with glaucoma. In all three groups, the slope of glaucoma, reaching 100% of stimuli seen with the brightest stimulus at the moderately damquency-of-seeing CA),was correlated highly 24-2.threshold orpotential normal Leandro, curves. program with the If a threshold deviation, the frequency-of-seeing curve intensity andlocation. Reaction were randomized. To determine aged test location time at the frequency of seeing 50% estimated threshold showed the no significant differences among the groups. RT from the In althoughwith suspected glaucoma and patientspatients even after compared with the a total normalcorrelationthree andhigher in glaucoma, with controllingwith subjects or subject had was significantlymore the normal subjects suspected adjacent points for the patients with false-positive asand false-negative Prolongation of intensity. The 0-dB value was responses, 60-dB and analyzed a function of increasing attenuation of stimulus results fit the range of the threshold and threshold deviation. For this reason, the authors found considerequation RT = a b(Intensityf for all glaucoma,different frequency-of-seeingat the P < 0.05 levelwithin the group adjacent deviation score curves, between subject groups and also 135, 225, ably we tested locations along the 45, or two of 0-dB stimuli were+ presented groups.times at each subjects and patients 20 in RT between normal location. Conclusions. There is no significant difference points with a total deviation score at subjects <with or 315 patients with glaucoma,chosenwith the same threshold .Innormalthe Pand patients level meridian, in locations randomly. patients 0.05 with Therefore,glaucoma eitherlocation towas tested aReaction time of 205 each at threshold or suprathreshold stimuli. total increases after Conclusions. There may be fundamental differences in areas of

Open Perimeter Interface

1990: The Humphrey Field Analyzer can be controlled from an external PC (Gateway). 1996

1993

Open Perimeter Interface

2006: At ARVO, Turpin, Artes, McKendrick discuss the idea of an open-source perimeter:

A new instrument that can serve as platform for experiments and clinical studies, and is open to all.

Open Perimeter Interface

But: excellent hardware already exists (Zeiss, Haag-Streit, Heidelberg, Oculus, Tinsley, Medmont, etc). 2010: Octopus Research Group: Uli Schiefer (Tbingen) & Matthias Monhart (Haag-Streit) First draft of OPI by Turpin (with Dietzsch and Demirel)

OPI Open Perimeter Interface Version 0.3

Preamble

This document describes a standard set of R functions for interfacing with a perimeter (an instrument for examining visual elds). It began existence at the First Octopus Research Meeting held in Tbingen in July 2010, which was hosted by Prof. Ulrich Schiefer (University of Tbingen), u u and Matthias Monhart (Haag-Streit). R code that implements this interface should provide the set of functions described.

1.1
0.0 0.1 0.2 0.3

Document History
3 Jul 2010 7 Jul 2010 17 May 2011 9 July 2011 Began in Hotel Hospiz, Tbingen by Andrew Turpin. u Complete rewrite with feedback from Janko Dietzsch and Shaban Demirel. Redraft by Andrew Turpin based on extensive feedback over a few rounds from Paul Artes and Shaban Demirel. image added to stimuli and a few errors in examples xed by Turpin.

1.2

Document Future

It is expected that this document will be revised at meetings of the Imaging and Perimetry Society.

1.3

Conventions

Open Perimeter Interface

June 2011: PHA and AT (via skype) meet with engineers at Haag-Streit in Berne, Switzerland, to discuss the implementation It nally becomes clear how exactly to do this: 1) The OPI species a small set of low-level commands 2) Manufacturers implement in any way they like (eg. Java, C++, Python), and make available (free, or for $) 3) Researchers call the OPI functions from any programming language they like. (We like )

Open Perimeter Interface

2 Data Types
opiStaticStimulus
stim <- list(x, y, image=NA, level, size=0.43, color="white", duration=200, responseWindow=1500, ...) class(stim) <- "opiStaticStimulus" x y image level size color duration responseWindow ... x coordinate of the center of stimulus in degrees relative to xation y coordinate of the center of stimulus in degrees relative to xation an image to display in a machine specic format stimulus level in cd/m2 (ignored if !is.na(image)) diameter of target in degrees, or scaling factor for image if specied machine specic stimulus color settings (ignored if !is.na(image)) total stimulus duration in milliseconds maximum time (>= 0) in milliseconds to wait for a response from the onset of the stimulus presentation machine specic parameters

opiTemporalStimulus

opiInitialize image=NA, lut, size=0.43, color="white", rate, duration, stim <- list(x, y, (Oct900) responseWindow=1500, ...) opiSetBackground (10, white) class(stim) <- "opiTemporalStimulus" stim <- list(list (x=-3, y=-3, level=318, size=0.43, color="white")) x x "opiStaticStimulus" class (stim) <-coordinate of the center of stimulus in degrees y y coordinate of the result <- opiPresent display center of stimulus in degrees (stim)machine specic format image an image to in a
lut if is.na(image) then this is a lookup table (vector) for stimulus level at each step of rate Hz in cd/m2 . If image is specied, then this is a list of images, in the same format as image, that is stepped through at rate Hz. diameter of target in degrees, or scaling factor for image if specied

size

Fifty-six years ago the Allies liberated Europe. Now, the OPI can liberate visual eld research (and more). Join us. There is much space on this truck.

What we can do now...

10000 asb 100 1000

eg: Psychometric functions for static perimetry (stimulus size, contrast, duration).

Goldmann IV

Goldmann III

0.0625

0.125

0.25

1 1.41 2 2.83 4 5.66 8 11.3 16 22.6 32

Goldmann V 128

Goldmann II

Goldmann I

10

mm^2 1/16

1/4

16

64

stimulus area, mm^2

256
256

0.5

64

Thank you!

The way forward...