Clinical Article

Perimetric early diagnosis of primary open angle glaucoma

Share article
1Eye Clinic at Wittembergplatz - Berlin, Germany
2Eye Clinic at Wittembergplatz - Berlin, Germany
Keywords. glaucoma
frequency doubling perimetry
blue-yellow perimetry
static achromatic perimetry


Primary open angle glaucoma (POAG) is a progressive optic neuropathy that comes along with systemic neurodegeneration. Clinical progression is often slow and discovered by the patient at a very late stage. Examining the visual field can help to detect scotomas, which indicate deficit or partial loss of the visual field. However, incipient visual field defects will remain undetected by static achromatic perimetry (SAP) until approximately 30% of the retinal ganglion cells have been lost. New perimetric methods have thus been developed to be able to obtain an earlier diagnosis.

Material and Methods:

This study is a subjective compilation on the topic of early perimetry with a focus on frequency doubling perimetry. The bibliographic research was performed on PubMed in the period between 2000 and 2022.


Blue-yellow and frequency doubling perimetry are perimetric methods that can detect the first scotomas 3-5 years earlier than SAP.


At least one early perimetric method should be available in a glaucoma consultation in order to make an early diagnosis of POAG in combination with clinical findings and imaging results.


Primary open angle glaucoma (POAG) is no longer considered an isolated optic neuropathy, but a systemic neurodegeneration.1,2 In addition to the glaucoma-typical changes, which involve the entire visual system (corpus geniculatum laterale, radiatio optica, visual cortex), there are also generalised cerebral impairments with synaptic connection disorders3,4, which involve both the central autonomic network and the peripheral autonomic nervous system.3,4,5 The visual system is a complex structure that is interconnected via 4 neurons, which link the retina to the visual cortex. It starts at the photoreceptors (1st neuron) and the bipolar cells (2nd neuron), and then continues via the retinal ganglion cells (3rd neuron) to the corpus geniculatum laterale (4th neuron), a neuronal relay station in which the input from the eye is connected to the brain and processed and vice versa. From there, it goes via the radiatio optica to the visual cortex in the V1 region (occipital lobe).35 The retinal ganglion cells are roughly divided into 3 large groups6:

  1.  The magnocellular ganglion cell system (approx. 10%), which has a low spatial and a high temporal resolution. It is primarily responsible for motion, depth and contrast perception.
  2. The parvocellular ganglion cell system (approx. 80%) with a high spatial but low temporal resolution. It is responsible for visual acuity and red/green colour vision.
  3. The koniocellular ganglion cell system (about 10%), which represents a direct connection to the blue cone bipolar cells and is responsible for blue-yellow colour vision.

It is important to note, however, that the visual system does not end in the V1 region. Starting from the V1 region, there exists a dorsal path through the parietal lobe (V2, V5, medial superior temporal area (MST)), which is responsible for the control of actions or the perception of movement and position and goes through the magnocellular ganglion cell system. In addition, there is a ventral path through the temporal lobe, which is responsible for the recognition of objects and for the perception of colour, pattern and shape and is located in the parvocellular ganglion cell system.7,8,9 The importance of the visual system is evidenced by the large proportion of the cerebral cortex that is involved in the act of vision. In addition to the primary visual cortex (V1), which accounts for about 15% of the total cerebral cortex, more than 30 different visual areas have been described so far. Overall, about 60% of the cerebral cortex is involved in the perception, interpretation and response to visual stimuli.10 Regarding glaucoma, cerebrospinal fluid circulation disorders with reduced cerebrospinal fluid pressure occur in the brain in patients with normal tension glaucoma (NTG) as well as in patients with POAG compared to control groups of a similar age.12 In this context, the literature also discusses the involvement of the glymphatic system in POAG.11

The question of how this systemic glaucomatous neurodegeneration occurs has not yet been clarified. On the one hand, there is the hypothesis that cerebral changes in POAG are a consequence of anterograde transsynaptic diffusion of cell death signals caused by the degeneration of the retinal ganglion cells themselves.13 On the other hand, it is also discussed in the literature that the above-mentioned  disturbances in the visual system may represent a consequence of a retrograde transsynaptic degeneration.14,15 This would mean that the cerebral changes in POAG occur very early on and appear earlier than or simultaneously with glaucomatous optic neuropathy. This pathophysiological concept is supported by the observation that POAG exhibits a primary mitochondriopathy16,17 that does not selectively affect the optic nerve. Increased triggering of oxidative stress causes neuroinflammation17, which has a far-reaching influence on the CNS. Regardless of the underlying process, or probably rather due to the interplay of both processes, glaucomatous optic neuropathy also involves long-term decline of retinal ganglion cells (RGC) with a loss of their axons. From a neurophysiological point of view18, when the natural cellular compensation mechanisms are exhausted, RGC struggle to survive. The first functional failures appear when the harmful stimuli act chronically on the RGC. However, these damages can be reversed if the general conditions for the RGC improve again, for example by reducing the intraocular pressure significantly, improving ocular perfusion, optimization of present systemic diseases and/or avoiding unnecessary harmful factors, such as smoking.

Perimetric methods

 Sensitive perimetric methods are required to be able to detect these early functional signs. Conventional achromatic perimetry is not adequate in this regard, since it only detects functional disorders after about 30% of the RGC have been lost.19 For this reason, numerous new perimetric techniques have come onto the market in the last 20 years in order to be able to detect functional damage earlier, especially in the case of early initial damage and the onset of the progression. One of the first developments in this direction was blue-yellow perimetry, which is an inexpensive early perimetry method, especially in younger glaucoma patients (< 55 years), since it can often be obtained by a software update of the classic perimeter. The introduction of quick strategies also in blue-yellow perimetry has eliminated the problem of a longer examination time. However, the main disadvantage of blue-yellow perimetry is its age-related restriction of use, because the yellow coloration of the lens and the loss of blue cones lead to less reliable results from the age of 55. Newer perimetric procedures with a movement stimulus are age-independent and can be used easily both in children and in older patients. Currently, the following methods are commercially available: frequency doubling perimetry (Matrix, Zeiss Meditec), pulsar perimetry (Octopus 600-Pulsar, Haag-Streit) and flicker perimetry (Heidelberg Edge Perimeter, Heidelberg Engineering). What all three of these perimetric techniques have in common is that they use a moving stimulus rather than a static one, as in static achromatic perimetry (SAP), in which the stimulus can only be distinguished from its background by means of the difference in luminance. In addition to the parvocellular ganglion cells, the movement stimulus primarily addresses the magnocellular ganglion cells, which are responsible for perceiving motion. Since the proportion of magnocellular ganglion cells constitutes only about 10% of all RGC, early cell subsidence of these RGC can be noticed more quickly, since they cannot be compensated sufficiently well by the other magnocellular RGC (hypothesis of reduced redundancy). Most of the experience with these perimetry techniques is with frequency doubling perimetry (FDP). Already 20 years ago it could be shown that FDP can detect perimetric damage earlier than SAP20, which was then extensively confirmed by subsequent studies.21,22,23,39,40 Furthermore, it was shown that, with FDP, perimetric progression can be detected earlier than with SAP.24,25,38 In addition, FDP is more sensitive in the detection of glaucoma than multifocal VEP.26

However, FDP also has its limits. Due to its high sensitivity, it does not have enough capacity reserve for the visual field examination of an advanced glaucoma. Therefore, this perimetry method cannot replace achromatic perimetry as the gold standard, but it is a helpful addition in early diagnostics. In addition, as with all functional and structural examination techniques, systemic diseases can also lead to abnormalities in FDP results and overlap with glaucoma-related anomalies. Such interferences have been described, for example, for diabetes mellitus27,28 and Alzheimer's disease29,30. Furthermore, FDP can not be replaced by imaging diagnostics, since, in their currently available form, they are mainly used in the detection of dead RGC with loss of the retinal nerve fibre layer, which neurobiologically represents the end of an RGC and has nothing to do with early diagnosis. Recent developments in Optical Coherence Tomography (OCT) may provide an insight into the functional state of RGC (for example, with Polarization OCT31 or Adaptive Optics OCT32), but these techniques are not yet clinically available. There is a synergy to explore in the combined application of FDP and OCT. A new algorithm, for example, has improved significantly the specificity of glaucoma detection.33 In summary, these "newer" perimetric methods, representative of which is frequency doubling perimetry, allow for an earlier detection of scotomas in glaucoma in the initial diagnosis and progression assessment when compared with SAP. This is likely to include not only disorders in the optic nerve itself, but also cerebral neurodegenerative disorders within the framework of POAG34, which affect a large proportion of the brain.  As a result of the time gained thanks to the earlier detection of the scotomas, an antiglaucomatous therapy can be initiated earlier and thus the progression can be prevented or at least slowed down. However, specific cost-effectiveness studies are not available. FDP is considered the most useful of perimetric procedures in a study on the quality and cost effectiveness of screening procedures for the detection of primary open-angle glaucomas.36 Even the American Academy of Ophthalmology recommends FDP and blue-yellow perimetry for early diagnosis: "Frequency doubling technology and short-wavelength automated perimetry (SWAP) are two alternative testing methods shown to be helpful in screening for early visual field damage, especially when SAP is normal".37


Perimetric methods have been available for over 20 years, but they are still hardly used in the everyday diagnosis of glaucoma. They should therefore be applied more frequently in the future, since every year gained in the diagnosis means a longer life with fewer functional disorders for glaucoma patients, which has a positive influence on their quality of life. Thus, frequency doubling perimetry in particular has an important place in perimetric diagnostics both in early diagnosis and in progression evaluation.

Das Foto zeigt Carl Erb

About Carl Erb

Prof. Prof. h.c. Dr. med - Eye Clinic at Wittembergplatz - Berlin, Germany

Carl Erb is an APL Professor at the Charité University Hospital, Berlin, Chief Physician of the Eye Clinic at Wittenbergplatz, Berlin and Founding Director of the Private Institute for Applied Ophthalmology Berlin.

Chan, J. W., Chan, N. C. Y., Sadun, A. A. (2021). Glaucoma as neurodegeneration in the brain. Eye Brain, 13, 21-28.
Wey, S., Amanullah, S., Spaeth, G. L., Ustaoglu, M., Rahmatnejad, K., Katz, L. J. (2019). Is primary open-angle glaucoma an ocular manifestation of systemic disease? Graefes Arch. Clin. Exp. Ophthalmol., 257, 665-673.
Nuzzi, R., Dallorto, L. (2018). Rolle T. Changes of Visual Pathway and Brain Connectivity in Glaucoma: A Systematic Review. Front. Neurosci., 12,363.
Sabel, B. A., Lehnigk, L. (2021). Ist Stress die primäre Ursache von Glaukom? Monbl. Augenheilkd. 238,132-145.
Sklerov, M., Dayan, E., Browner, N. (2019). Functional neuroimaging of the central autonomic network: recent developments and clinical implications. Clin. Auton. Res., 29, 555-566.
Nassi, J. J., Callaway, E. M. (2009). Parallel processing strategies of the primate visual system. Nat. Rev. Neurosci., 10, 360-372.
Yamasaki, T., Maekawa, T., Fujita, T., Tobimatsu, S. (2017). Connectopathy in Autism Spectrum Disorders: A Review of Evidence from Visual Evoked Potentials and Diffusion Magnetic Resonance Imaging. Front. Neurosci., 11, 627.
Prasad, S., Galetta, S. L. (2011). Anatomy and physiology of the afferent visual system. Handb. Clin. Neurol., 102, 3-19.
Herlin, B., Navarro, V., Dupont, S. (2021). The temporal pole: From anatomy to function-A literature appraisal. J. Chem. Neuroanat., 113,101925.
Gegenfurtner, K. R., Walter., S.,Braun, D.I. (2002) Visuelle Informationsverarbeitung im Gehirn In: Bild | Medien | Wissen. Visuelle Kompetenz im Medienzeitalter (eds. Huber, H. D., Lockermann, B.,Scheibel, M.) Kopaed Verlag, München.
Wostyn, P., De Groot, V., Van Dam, D., Audenaert, K., Killer, H. E., De Deyn, P. P. (2017). The glymphatic hypothesis of glaucoma: A unifying concept incorporating vascular, biomechanical, and biochemical aspects of the disease. Biomed. Res., 5123148.
Jonas, J. B., Wang, N., Yang, D., Ritch, R., Panda-Jonas, S (2015). Facts and myths of cerebrospinal fluid pressure for the physiology of the eye. Prog. Retin. Eye Res, 46, 67-83.
Calkins, D. J. (2012). Critical pathogenic events underlying progression of neurodegeneration in glaucoma. Prog. Retin. Eye Res., 31, 702-719.
Murphy, M. C., Conner, I. P., Teng, C. Y. Lawrence, J. D., Safiullah, Z., Wang, B., Bilonick, R. A., Kim, S-G., Wollstein, G., Schuman, J. S., Chan, K. C. (2016). Retinal Structures and Visual Cortex Activity are Impaired Prior to Clinical Vision Loss in Glaucoma. Sci. Rep., 6, 31464.
Nuzzi, R., Dallorto, L. (2018). Rolle T. Changes of Visual Pathway and Brain Connectivity in Glaucoma: A Systematic Review. Front. Neurosci. 12, 363.
Abu-Amero, K. K., Morales, J., Bosley, T. M. (2006). Mitochondrial abnormalities in patients with primary open-angle glaucoma. Invest. Ophthalmol. Vis. Sci., 47,2533–2541.
Duarte, J. N. (2021). Neuroinflammatory Mechanisms of Mitochondrial Dysfunction and Neurodegeneration in Glaucoma. J. Ophthalmol., 4581909.
Porciatti, V., Ventura, L. M. (2012). Retinal ganglion cell functional plasticity and optic neuropa-thy: a comprehensive model. J. Neuroophthalmol. 32, 354-358.
Medeiros, F. A., Lisboa, R., Weinreb, R. N., Liebmann, J. M., Girkin, C., Zangwill, L. M. (2013). Retinal ganglion cell count estimates associated with early development of visual field defects in glaucoma. Ophthalmo­logy, 120, 736-744.
Bayer, A. U., Erb, C. (2002). Short wavelength automated perimetry, frequency doubling technology perimetry, and pattern electroretinography for prediction of progressive glaucomatous standard visual field defects. Ophthalmology, 109, 009-1017.
Lee, M. J., Kim, D. M., Jeoung, J. W., Hwang, S.-S., Kim, T. W., Park, K. H. (2007). Localized retinal nerve fiber layer defects and visual field abnormalities by Humphrey matrix frequency doubling technology perimetry. Am. J. Ophthalmol., 143, 1056-1058.
Fan, X., Wu, L. L., Xiao., G. G., Ma, Z. Z., Liu, F. (2018). The 8-year follow-up study for clinical diagnostic potentials of frequency-doubling technology perimetry for perimetrically normal eyes of open-angle glaucoma patients with unilateral visual field loss. Zhonghua Yan Ke Za Zhi, 54,177-183.
Hu, R., Wang, C., Racette, L. (2017). Comparison of matrix frequency-doubling technology perimetry and standard automated perimetry in monitoring the development of visual field defects for glaucoma suspect eyes. PLoS One, 12, e0178079.
Meira-Freitas, D., Tatham, A. J., Lisboa, R., Kuang, T. M., Zangwill, L. M., Weinreb, R. N., Girkin, C. A., Liebmann., J. M., Medeiros, F. A. (2014). Predicting progression of glaucoma from rates of frequency doubling technology perimetry change. Ophthalmology, 121,498-507.
Liu, S., Yu, M, Weinreb, R. N., Lai, G., Lam, D. S., Leung, C.K (2014). Frequency doubling technology perimetry for detection of visual field progression in glaucoma: a pointwise linear regression analysis. Invest. Ophthalmol. Vis. Sci. 55, 2862-2869.
Kanadani, F. N., Mello, P. A., Dorairaj, S. K., Kanadani, T. C. (2014). Frequency-doubling technology perimetry and multifocal visual evoked potential in glaucoma, suspected glaucoma, and control patients. Clin. Ophthalmol. 8, 1323-1330.
Montesano, G., Ometto, G., Higgins, B. E., Das, R., Graham, K. W., Chakravarthy, U., McGuiness, B., Young, I. S., Kee, F., Wright, D. M., Crabb, D. P., Hogg, R. E. (2021). Evidence for Structural and Functional Damage of the Inner Retina in Diabetes With No Diabetic Retinopathy. Invest. Ophthalmol. Vis. Sci. 62, 35.
Bao, Y. K., Yan, Y., Gordon, M., McGill, J. B., Kass, M., Rajagopal, R. (2019). Visual Field Loss in Patients With Diabetes in the Absence of Clinically-Detectable Vascular Retinopathy in a Nationally Representative Survey. Invest. Ophthalmol. Vis. Sci. 60, 4711-4716.
Cesareo, M., Martucci, A., Ciuffoletti, E., Mancino, R., Cerulli, A., Sorge, R. P., Martorana, A., Sancesario, G., Nucci. C (2015). Association Between Alzheimer‘s Disease and Glaucoma: A Study Based on Heidelberg Retinal Tomography and Frequency Doubling Technology Perimetry. Front. Neurosci., 9, 479.
Valenti, D. A. (2013). Alzheimer‘s disease: screening biomarkers using frequency doubling technology visual field. ISRN Neurol., 989583.
De Boer, J. F., Hitzenberger, C. K., Yasuno, Y. (2017). Polarization sensitive optical coherence tomography – a review. Biomed. Opt. Express, 8,18381873.
Dong, Z. M., Wollstein, G., Wang, B., Schuman, J. S. (2017). Adaptive optics optical coherence tomography in glaucoma. Prog. Retin. Eye Res. 57, 76-88.
Morejon, A., Mayo-Iscar, A., Martin, R., Ussa, F. (2018). Development of a new algorithm based on FDT Matrix perimetry and SD-OCT to improve early glaucoma detection in primary care. Clin. Ophthalmol. 13, 33-42.
Reilly, M. A, Villarreal, A., Maddess, T., Sponsel, W. E. (2015). Refined Frequency Doubling Perimetry Analysis Reaffirms Central Nervous System Control of Chronic Glaucomatous Neurodegeneration. Transl. Vis. Sci. Technol., 4, 7.
Heermann, S. (2017). Neuroanatomy of the Visual Pathway. Klin. Monbl. Augenheilkd., 234,:1327-1333.
Antony, K., Genser, D., Fröschl, B. (2007). Validity and cost-effectiveness of methods for screening of primary open angle glaucoma. GMS Health Technol. Assess, 7, 3, Doc 1.
Gedde, S. J., Lind, J. T., Wright, M. M., Chen, P. P., Muir, K. W., Vinod, K., Li, T., Mansberger, S. L. (2021). American Academy of Ophthalmology Preferred Practice Pattern Glaucoma Panel. Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern®. Ophthalmology. 128, P151-P192.
Iwase, A., Tsutsumi, T., Fujii, M., Sawaguchi, S., Araie, M. (2022). Risk factors for glaucoma are reflected in abnormal responses to frequency-doubling technology screening in both normal and glaucoma eyes. Sci. Rep., 12, 11705.
Kim, S. A., Park, C. K., Park, H. L. (2022). Comparison between frequency-doubling technology perimetry and standard automated perimetry in early glaucoma. Sci. Rep., 12, 10173.
Terauchi, R., Wada, T., Ogawa, S., Kaji, M., Kato, T., Tatemichi, M., Nakano, T. (2020). FDT Perimetry for Glaucoma Detection in Comprehensive Health Checkup Service. J. Ophthalmol., 4687398.