Patient awareness of binocular central scotoma in age-related macular degeneration

Abstract

Purpose: To assess whether age-related macular degeneration (AMD) patients are aware of binocular central visual field defects.

Methods: One hundred fifty-three consecutive AMD patients in their initial low-vision rehabilitation evaluation were immediately asked at the beginning of their visit (1) whether they were able to see any blind spots or defects in their field of vision and (2) whether they had any evidence or experiences that led them to believe that they had defects in their field of vision. They then had their vision assessed by binocular central visual field testing using the California Central Visual Field Test, binocular reading performance evaluated using the Smith-Kettlewell Reading Test (SK Read) and MN Read charts, and visual acuity measured using the ETDRS chart at 1 meter. Mean diameters of the scotomas with borders near fixation were noted.

Results: Visual acuity median was 20/253 (range 20/40 to hand movements). Binocular scotomas were present in 88% of patients (66% had dense scotoma). Of patients with binocular scotomas, 56% were totally unaware of their presence, even with dense scotomas measuring up to 30° in diameter; 1.5% could fleetingly see a defect in their visual field on waking; and 44% related experiences of things "disappearing" on them. The median and range of scotoma diameters for those unaware vs. those with some awareness of their scotomas were comparable. There was no significant relationship of awareness of the scotoma with age, acuity, scotoma size, density, or duration of onset. Awareness of scotoma was associated with fewer errors on the SK Read (p < 0.01).

Conclusions: Low vision clinicians cannot depend on patients to report the presence of significant scotomas; thus, appropriate testing must be performed. Presence of scotomas decreased reading accuracy, but some awareness of the scotomas had a tendency to improve accuracy. The value of rehabilitation programs aimed at increasing patient awareness of their scotomas may be supported by this evidence.