When I started doing low vision, I didn’t really understand the significance of patchy macular fields. As time has gone on, I’ve realised that understanding them is critical to understanding the apparent paradox of patients who complain of poor vision but still have great VA. This can occur in any posterior pathology, but is particularly common with macular degeneration and glaucoma.
Drusen never sleep
When I started out in optometry, I had the impression that AMD degraded the macula in a fairly even way, and that glaucoma didn’t affect the macular fields until quite late. As it turns out, neither of these things is true.
In fact, in dry AMD the degeneration is quite focal. Drusen often appear around the macula in a roughly circumlinear pattern, creating small dense scotomas that gradually start coalescing to form larger scotomas. Frequently the fovea is spared until the very last, so the patient goes through a period where they have a large horseshoe or ring scotoma.
With wet AMD, the scotoma is much more random, but again if the fovea is not involved the patient can have excellent VA while still having quite complex and dense scotomas right next to fixation.
We’re used to thinking of early glaucomatous field loss as tending to be arcuate, corresponding to the retina just outside of the macula, and only constricting in to the macula later in the disease process. More recent research has shown that’s not the case. Alison McKendrick’s work at the University of Melbourne has shown that typical 24-2 or 30-2 field testing misses macular field loss, since those analyses only include four points in the macular area. Doing a 10-2 will frequently show up scotomas that were missed, but which are functionally significant.
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