AUTOMATED THRESHOLD-RELATED OBJECTIVE PERIMETRY

Abstract: A system for an examination of an eye of a patient. The system (11) is able to substantially automatically determine the pupillary response without manual intervention from the patient. In addition, the system is able to compensate for eye and head (13) movements, such that the patient does not need to remain in an immobile, upright position during the test. The system preferably includes a grid of light sources (19) attached to a housing which covers the eyes of the patient. The light sources in the grid can be individually activated in order to stimulate different areas of the retina for testing.

Description: AUTOMATED THRESHOLD-RELATED OBJECTIVE PERIMETRY FIELD AND BACKGROUND OF THE INVENTION The present invention is concerned with methods and equipment for diagnostic tests of the eyes, and more particularly, with an automatic system for examination of the field of vision of a patient. The system is equipped to continuously track eye movement so as to focally project a spot of light stimuli on preselected retinal areas, regardless of the direction of the gaze of the patient or of the orientation of the head of the patient. The system can concomitantly measure the pupil size and/or the intensity of light reflected through the pupil as a result of the light projected. The system is optionally mounted on a head set, but alternatively and preferably is mounted on a housing which is only partially supported by the head of the patient. The examination of the field of vision of a patient is an extremely important diagnostic tool used to identify and analyze diseases and defects of the retina and visual pathways, such as glaucoma, optic neuropathy, multiple sclerosis and compression of the visual pathways. In the past, such an examination was performed with manually operated field of vision test instruments known as perimeters. Manually operated perimeters require the services of a physician or a skilled technician in order to examine the patient. In the most widely used system, known as the Goldmann system, the patient must sit still, head clamped in place, and constantly watch a fixation target at the center of a screen to eliminate any uncertainties caused by head and eyes movements. A small point of light of varied intensity, size and color is projected onto the screen and its position is varied by the operator. The limits of the visual field are determined on the basis of the manual or verbal indications of the patient as to when the point of light comes into or goes out of view, while the light is moved radially between the periphery and the center of the patient's view. The examiner must continuously watch the patient to ascertain that the eye of the patient is fixated on the center of the screen, since the examination results are artefactual if the eyes of the patient are not immobile. Therefore, the examination of the extent of the field of vision using the commonly available Goldmann system is basically subjective, and is dependent to a large extent on the skill of the examiner, the fatigue level of the patient and the ability of the examiner to communicate with the patient. Thus, the Goldmann system is not suitable for small children and patients who must remain in a supine position. More recently, automatic perimeters have been marketed and used. However, even these instruments rely upon the Goldmann system and incorporate the control of a microprocessor in order to more efficiently measure the effect of light stimuli from external sources. Other prior art instruments have added a head set or helmet to eliminate any effect of head movements on the final results, as disclosed in United Kingdom Application No. 2096791 and two reports from the IOVS [J. Whiteside-Michel et ah, "Virtual Reality Visual Field Test. .", IOVS/97, 38:4, S569; and L. Brigatti et al, "Virtual Perimetry: A Novel Perimetric Technique", IOVS/97, 38:4, S572]. Alternatively, various systems have been disclosed which use more objective means for perimetry such as pupillary size determination during Humfrey perimetry, as disclosed in U.S. Patent No. 5,490,098. U.S. Patent No. 5,114,222 discloses a method which includes a light stimulus moved in a continuous circular path according to decreased pupillary response. U.S. Patent No. 5,459,536 discloses an instrument which includes a device to track eye movement, so that such movements can be incorporated into the final analysis of the results. U.S. Patent No. 5,530,495 discloses an instrument which features a plurality of light stimuli, but which is intended to generate images for display to the patient. However, all of these instruments and methods perform indirect measurements in which the light stimulus is projected in front of the eyes of the patient, rather than directly stimulating the retinal nerve fibers with light. There is thus an unmet medical need for a method and a system which objectively examines the visual field of a patient in which the retinal nerve fibers are stimulated by a retinal threshold- related light stimulus, such that the change in pupillary size in response to this light is automatically measured, and such that this measurement is optionally cross-checked by determination of the change in the amount of light reflected from the retina, such that the patient does not need to remain substantially immobile during the examination and such that the method and system can be used to examine patients which must remain supine or who cannot otherwise comply with the requirements of prior art manual perimetry methods. SUMMARY OF THE INVENTION According to the present invention, there is provided a system for an examination of an eye of a patient, the system comprising: (a) a housing at least partially surrounding the head of the patient; (b) a plurality of light sources for projecting light from at least one of the light sources directly to the eye of the patient to form reflected light; (c) a light receiving device attached to the housing to receive the reflected light and to transmit a signal according to the reflected light; and (d) a microprocessor for receiving the signal and for analyzing the signal to determine a pupillary light response. Preferably, the light is projected directly to a retina of the eye of the patient. More preferably, the light sources are in a form of a dense grid, such that a particular light source is able to illuminate a specific area of the retina. Most preferably, the microprocessor transmits a return signal to the light sources, such that the particular light source is selected according to the location of the pupil in order to illuminate the specific area of the retina. Also most preferably, a characteristic of light projected by the at least one light source is determined according to the return signal, the characteristic being selected from the group consisting of an intensity and a wavelength of the light. Preferably, the reflected light is reflected from the retina, such that the pupillary response is determined according to an amount of the reflected light. Also preferably, the light sources include an infrared light source for illuminating the eye and the light receiving device also collects a visual image of the pupil, such that the pupillary response is determined according to a size of a pupil of the eye. More preferably, the visual image indicates an apparent shape of the pupil, such that a location of the pupil and a position of the eye relative to the light receiving device is determinable from the apparent shape. Preferably, the light source is of a type selected from the group consisting of halogen lamp, mercury arc lamp, LED and coherent light source. More preferably, the mercury arc lamp features a plurality of optic fibers for focusing the projected light on the retina of the eye. Also more preferably, the halogen lamp features a plurality of optic fibers for focusing the projected light on the retina of the eye. Preferably, the system further includes (e) a screen attached to the housing, such that the eye of the patient is covered by the screen, and such that the light sources are attached to the screen. The screen is preferably selected from the group consisting of a flat screen and a hemispherical screen. More preferably, the system further includes (g) a background light source for background illumination of the screen. Also preferably, the system further includes (e) a lens for focusing the projected light from the light sources on the eye of patient; and (f) a light orientor for orienting the projected light to an axis of vision of the eye of the patient. Preferably, the light orientor is a beam-splitter. According to another embodiment of the present invention, there is provided a method for determining a visual field of an eye of a patient, the method comprising the steps of: (a) providing an instrument for determining the visual field, the instrument featuring: (i) a housing for covering the eye of the patient; (ii) a plurality of light sources attached to the housing; (iii) an eye tracking device attached to the housing; (iv) a light receiving device attached to the housing; and (vi) a microprocessor; (b) continuously following a position of the eye with the eye tracking device; (c) projecting light from at least one of the light sources directly onto a preselected area of a retina of the eye, the light being at a variable intensity; (d) measuring an amount of reflected light from the eye with the light receiving device; (e) calculating a pupillary light response from the amount of reflected light according to the position of the eye with the microprocessor; and (f) determining the visual field of the eye from the pupillary light response. Preferably, the projected light is projected directly onto a retina of the eye. More preferably, the step of measuring the reflected light includes the step of measuring a visual image of a pupil of the eye. Most preferably, the pupillary light response is also determined from the visual image of the pupil. Hereinafter, the term "patient" refers to any subject, particularly a human or higher mammal, capable of being examined with the system of the present invention. BRIEF DESCRIPTION OF THE DRAWINGS The invention is herein described, by way of example only, with reference to the accompanying drawings, wherein: FIG. 1 is an illustration of one embodiment of the system of the present invention; and FIG. 2 is a schematic block diagram of a particularly preferred embodiment of the system of the present invention. DESCRIPTION OF THE PREFERRED EMBODIMENTS The present invention is of an automatic perimetry system, including an instrument for automated perimetry measurements and a method for operating the instrument. The system includes a housing for at least partially covering the eyes of the patient, for example in the form of a headset to be placed on the head of a patient, and more preferably for at least partially surrounding the head of the patient. Alternatively and preferably, the housing could extend beyond the head of the patient. Such a housing could be supported by the arms or shoulders of the patient, or by an inanimate support which could be attached to a chair or to the ground, for example. The housing preferably supports a screen, which is preferably illuminated with background illumination; an eye tracking device; a plurality of light sources for focal retinal stimulation; and two light receiving devices, one for each eye. The screen is optionally either flat or hemispherical. In addition, preferably the housing supports a beam splitter, for focusing the light received from the light sources on the eye, and for transmitting the light reflected from a portion of the eye to a light receiving device, such as a camera. One or more lenses may also optionally be featured for further focusing the light received from the light sources on the eye. The light sources are preferably capable of emitting light of an adjustable intensity, such that the intensity of the light matches the threshold of the retina to light stimuli. Preferably, each light receiving device is able to follow the position of the eye, to measure the amount of light reflected from the retina, and to visually capture an image of the pupil itself. Thus, the eye tracking device is preferably incorporated within the light receiving device, such that the eye tracking device is able to follow the position of the eye, preferably continuously. The output of the light receiving devices, in terms of both the amount of light reflected from the retina and the image of the pupil, is sent to a microprocessor. From this output, the microprocessor continuously calculates both the resulting pupillary area and the correct amount of reflected light to determine the pupillary light response. Preferably, the microprocessor incorporates information about the position of the eye relative both to the particular active light source and to the light receiving device, such that even if the eye moves, the pupillary light response can be accurately determined. The position of the pupil relative to the light receiving device and the light sources can be determined from the visual image of the pupil. When the pupil is viewed straight on, the pupil appears to be round. If the eye moves so that the pupil is now viewed at an angle, the shape of the pupil appears to change to an oval. Thus, the microprocessor, or more accurately the software instructions performed by the microprocessor, is able to determine the position of the pupil from the visual image. The microprocessor also directs the light emission from the different light sources to preselected loci on the retina of the eye of the subject, according to the above analysis of the output of the light receiving devices. For example, in order to stimulate one particular area of the retina, the microprocessor must select one particular light source which is focused on that area. In order to determine which light source should be selected, the microprocessor preferably first determines the position of the eye, and hence of the retina, relative to the plurality of light sources. Next, the particular light source which can stimulate the desired retinal area at that moment is selected. The output of the light receiving device is then analyzed as described previously. Since both the light emission source and the light receiving devices are attached to the housing, the pupil size, amount of reflected light and eye movement can be continuously monitored. Such continuous monitoring permits consensual pupillary monitoring whereby movement of the head and eyes of the patient during perimetry testing does not affect the test results, thus objectively measuring the visual field by automatic determination of the pupillary light response. The principles and operation of a system according to the present invention may be better understood with reference to the drawing and the accompanying description. Referring now to the drawing, Figure 1 illustrates the automatic perimetry system of the present invention. A system 11 includes a head set 12, in a view partially cut away to show the interior. Head set 12 is attached to the head 13 of a patient, preferably by straps 14. Head set 12 preferably has an oval shape with a hemispherical construction covering the eyes and the upper part of the face of the patient. Such a construction enables a screen 16 to be placed within head set 12. A plurality of light sources 19 are attached to screen 16. Preferably, screen 16 is very close to the eyes of the patient, even as close as about 2 cm. Also preferably, light sources 19 substantially cover the surface of screen 16 in the form of a dense grid, for example. Such a grid enables a particular light source 19 to be selected for emitting light in a highly focused manner. Also, such a grid eliminates the need for any mechanical movement of light sources 19 in order to focus on a particular portion of the retina, since simply illuminating one particular light source 19 would stimulate only one specific area of the retina, automatically giving focus to the emitted light. Light sources 19 are preferably in the form of a LED, in which the light is generated by a power supply device 20 also attached to head set 12, more preferably mounted on the outer periphery of head set 12. Power supply device 20 is connected to light sources 19 through a cable 46. Alternatively and preferably, light could be generated by a halogen lamp or a mercury arc lamp connected to power supply device 20 and then directed to the retina by a bundle of fiber optics, the end of each fiber forming a point on the dense grid. Light source 19 could also be a coherent light source, such as a laser. Preferably, at least one light source 19 provides a background illumination of the eye, for example as white or monochromatic light source. Such background illumination is preferably substantially continuous. More preferably, such background illumination illuminates screen 16. Light is focused on a specific area of the retina regardless of any movements of the head or eyes of the patient for a number of reasons. First, light sources 19 are directly attached to head set 12 so that light sources 19 move with the movements of the patient. Second, in the preferred embodiment of a dense grid of light sources 19, a specific area of the retina is illuminated by the emission of light from one particular light source 19. These features enable the emitted light to be correctly reflected from the retina of the patient, if the amount of light reflected from the retina is being measured. Alternatively, these features enable an accurate image of the pupil, substantially free of distortion, to be received for the determination of pupillary response according to pupil size. In addition, light sources 19 have the advantage of being pulsed light sources, in the sense that light is preferably not transmitted continuously from light sources 19 (with the exception of background illumination and the infrared light source, if present). Such pulses enable the pupillary response to be more accurately determined by enabling the pupil to return to the basal state which occurred before the light waves were transmitted to the retina. Once light is reflected from the retina of the eye of the patient, the reflected light is detected by a light receiving device 21 mounted in the inner periphery of head set 12. Light receiving device 21 is preferably supplied with energy by power supply device 20 through a cable 39. Light receiving device 21 preferably is a CCD camera, although alternatively light receiving device 21 could be at least one photomultiplier tube. A CCD camera is more preferable because such a camera is capable of continuous video monitoring of the pupil, preferably including both the capture of a visual image of the pupil and the measurement of the amount of light reflected from the retina. Such information can be used to determine the position of the eye relative to the horizontal and vertical axes, as well as to cross-check the eye position by using the Hirshberg corneal reflex. Thus, light receiving device 21 preferably collects both a visual image of the pupil and the amount of light reflected from the retina, and then transmits this information in the form of signals. Alternatively, light receiving device 21 could receive only the visual image or only the amount of light reflected from the retina. These signals obtained by light receiving device 21 are then transmitted through a communication link such as a cable 41 to a microprocessor 26. Microprocessor 26 operates software (not shown), which permits the analysis of the received data to determine the measured pupillary light response. In particular, the software preferably first analyzes the visual image of the pupil in order to determine the location of the pupil relative to both the particular light source 19 which was illuminated, and to light receiving device 21. As noted previously, such an analysis optionally and preferably includes the determination of the apparent shape of the pupil from the visual image which gives information about the position of the pupil relative to light receiving device 21, and hence to light source 19. More preferably, the software is able to determine the size of the pupil from the visual image of the reflected infrared light received from an infrared light source 19. Next, the software preferably determines the size of the pupil both directly from the visual image and also from the amount of light reflected from the retina, which is determined by the size of the pupil. Alternatively, the software optionally only determines the size of the pupil either directly from the visual image or alternatively from the amount of light reflected from the retina. Finally, all of this information is analyzed to determine if the response to stimulation of a particular area of the retina was normal or abnormal. The software also uses the analysis to enable microprocessor 26 to send return signals to light sources 21 through a cable 17, causing the right intensity of light to be generated by the desired light source or sources 21, such that light is projected to an area of the retina selected by the software in order to more accurately assess the field of vision. Each area of the retina can thus be examined separately, regardless of the movement of the eye or the position of the pupil, without any voluntary activity on the part of the patient. Preferably the intensity of the light generated by the desired light source or sources 21 is also controlled according to the return signal. Preferably, microprocessor 26 is able to connect and download the data into a computer 28 or alternatively directly to a printer 29. According to other preferred embodiments, microprocessor 26 also controls the wavelength of light emitted by light sources 19. Such control could permit additional types of ocular examinations to be performed with system 11. Figure 2 shows a schematic block diagram of a second preferred embodiment of the system of the present invention. In this preferred system, a housing 48 preferably at least partially covers the eyes of the patient (not shown). More preferably, housing 48 features a nose piece and is able to substantially block any extraneous light from reaching the eyes of the patient. Housing 48 could optionally be partially supported by the patient, or alternatively and preferably could be supported by an inanimate support, such as a stand. The head of the patient (not shown) is placed within housing 48 such that light from a light source 50 is focused on each eye of the patient, preferably separately. Preferably, light source 50 is a plurality of light sources arranged in a grid, as for Figure 1 above. More preferably, light source 50 also includes an infrared light source, such as an infrared LED, for enabling substantially continuous measurement of the size of the pupil. In addition, light source 50 is a background light source, which could be a white light or monochromatic light source, for providing background illumination to the area in front of the eyes of the patient. Power is supplied to light source 50 through a power supply 52. Preferably, at least one lens 54, and more preferably two lenses 54 as shown, focus light from light source 50 on the eyes of the patient. More preferably, light passes through each lens 54 to a light orientor 56 for orienting the projected light to the axis of vision of the eye of the patient. Preferably, the light orientor is a beam-splitter. Next, light is reflected back from the eyes of the patient, for example from the retina of the eye, or alternatively from the pupil of the eye. This reflected light is passed through beam-splitter 56 to a light receiver 58, which may be a CCD camera for example. A light signal determined according to the light received by light receiver 58 is then stored in a memory 60, which may be any type of suitable, writable memory such as a flash memory, for example. The light signal is then analyzed by a computer software module 64. Preferably, computer software module 64 analyzes the amount of light reflected from the retina to determine pupillary response. Alternatively and preferably, computer software module 64 analyzes the visual image of the pupil to determine pupillary response. Most preferably, computer software module 64 analyzes both the visual image of the pupil and the amount of light reflected from the light of the retina to determine pupillary response. Computer software module 64 then sends one or more signals to controller 62 in order to control the activity of light source 50. For example, computer software module 64 could detect an apparent lack of pupillary response when light is directed to one part of the eye, and could then cause other points in the grid of light source 50 to be illuminated according to the area of the retina in which the problem was detected. Computer software module 64 is thus able to both analyze the results obtained and to control light source 50 according to these results in order to perform the test. While the invention has been described with respect to a limited number of embodiments, it will be appreciated that many variations, modifications and other applications of the invention may be made.

Claims: WHAT IS CLAIMED IS: 1. A system for an examination of an eye of a patient, the system comprising: (a) a housing at least partially surrounding the head of the patient; (b) a plurality of light sources for projecting light from at least one of said light sources directly to the eye of the patient to form reflected light; (c) a light receiving device attached to said housing to receive said reflected light and to transmit a signal according to said reflected light; and (d) a microprocessor for receiving said signal and for analyzing said signal to determine a pupillary light response. 2. The system of claim 1, wherein said light is projected directly to a retina of the eye of the patient. 3. The system of claim 2, wherein said light sources are in a form of a dense grid, such that a particular light source is able to illuminate a specific area of said retina. 4. The system of claim 3, wherein said microprocessor transmits a return signal to said light sources, such that said particular light source is selected according to said location of said pupil in order to illuminate said specific area of said retina. 5. The system of claim 4, wherein an characteristic of light projected by said at least one light source is determined according to said return signal, said characteristic being selected from the group consisting of an intensity and a wavelength of said light. 6. The system of claim 2, wherein said reflected light is reflected from said retina, such that said pupillary response is determined according to an amount of said reflected light. 7. The system of claim 1, wherein said light sources include an infrared light source for illuminating the eye and said light receiving device also collects a visual image of said pupil, such that said pupillary response is determined according to a size of a pupil of the eye. 8. The system of claim 7, wherein said visual image indicates an apparent shape of said pupil, such that a location of said pupil and a position of the eye relative to said light receiving device is determinable from said apparent shape. 9. The system of claim 1, wherein said light source is of a type selected from the group consisting of halogen lamp, mercury arc lamp, coherent light source and LED. 10. The system of claim 9, wherein said mercury arc lamp features a plurality of optic fibers for focusing said projected light on said retina of the eye. 11. The system of claim 9, wherein said halogen lamp features a plurality of optic fibers for focusing said projected light on said retina of the eye. 12. The system of claim 1, further comprising: (e) a screen attached to said housing, such that the eye of the patient is covered by said screen, and such that said light sources are attached to said screen. 13. The system of claim 1, further comprising: (e) a lens for focusing said projected light from said light sources on the eye of patient; and (f) a light orientor for orienting the projected light to an axis of vision of the eye of the patient. 14. The system of claim 13, wherein said light orientor is a beam-splitter. 15. The system of claim 14, further comprising: (g) a screen attached to said housing, such that the eye of the patient is covered by said screen, and such that said light sources are attached to said screen; and (h) a background light source for background illumination of said screen. 16. A method for determining a visual field of an eye of a patient, the method comprising the steps of: (a) providing an instrument for determining the visual field, the instrument featuring: (i) a housing for covering the eye of the patient; (ii) a plurality of light sources attached to said housing; (iii) an eye tracking device attached to said housing; (iv) a light receiving device attached to said housing; and (vi) a microprocessor; (b) continuously following a position of the eye with said eye tracking device; (c) projecting light from at least one of said light sources directly onto a preselected area of a retina of the eye, said light being at a variable intensity; (d) measuring an amount of reflected light from the eye with said light receiving device; (e) calculating a pupillary light response from said amount of reflected light according to said position of the eye with said microprocessor; and (f) determining the visual field of the eye from said pupillary light response. 17. The method of claim 16, wherein said projected light is projected directly onto a retina of said eye. 18. The method of claim 17, wherein the step of measuring said reflected light includes the step of measuring a visual image of a pupil of the eye. 19. The method of claim 18, wherein said pupillary light response is also determined from said visual image of said pupil.

Inventors: DAN JACOB, DAN, JACOB
Applicants: DAN JACOB, DAN, JACOB
Application year: 1998
Main classification: A61B3
IPC codes: A61B3