Not every ring scotoma is due to glaucoma
March 14, 2025

Not every ring scotoma is due to glaucoma

In advanced stages of glaucoma, patients may present with an annular scotoma, also known as ring scotoma, where the retinal sensitivity is concentrically reduced. However, not every patient with a ring scotoma has glaucoma. Retinal diseases such as retinitis pigmentosa or foveal spearing central retinal artery occlusions can lead to an annular scotoma too [1]. Clinical assessment allows differentiating these causes from each other. It becomes more difficult if no morphological cause for a ring scotoma can be found. Then a functional or refractive cause must be considered. The most common type of functional visual field loss is a concentric constriction of the peripheral vision forming a “tunnel vision” [2]. For the latter, moderate to severe hyperopic, as well as aphakic patients may show a refractive ring scotoma. It is an artefact caused by the high-powered and therefore thick glasses which are needed to perform visual field testing if contact lenses are not available. [3]. In addition, aphakic patients have an increased risk of developing glaucoma [4]. For this reason, the ring scotoma can be a pitfall in this group of patients and may lead to a misdiagnosis of glaucoma if clinical examination is not performed carefully.


References

  1. Senthil, S., Nakka, M., Sachdeva, V., Goyal, S., Sahoo, N., & Choudhari, N. (2021). Glaucoma Mimickers: A major review of causes, diagnostic evaluation, and recommendations. Seminars in Ophthalmology, 36(8), 692–712. https://doi.org/10.1080/08820538.2021.1897855
  2. Bruce BB, Newman NJ. Functional visual loss. Neurol Clin. 2010 Aug;28(3):789-802. doi: 10.1016/j.ncl.2010.03.012. PMID: 20638000; PMCID: PMC2907364.
  3. WELSH RC. The roving ring scotoma with its jack-in-the-box phenomenon of strong-plus (aphakic) spectacle lenses. Am J Ophthalmol. 1961 Jun;51:1277-81. PMID: 13784293.
  4. Chen TC, Bhatia LS, Halpern EF, Walton DS. Risk factors for the development of aphakic glaucoma after congenital cataract surgery. Trans Am Ophthalmol Soc. 2006;104:241-51. PMID: 17471345; PMCID: PMC1809898.


Contributor: Nathanael Haener, MD, Bern Switzerland

Example Image

Tip of the Month Manager: Karin Øyo-Szerenyi
Tip of the Month Editors: Karl Mercieca, Francisco Goñi
Tip of the Month Editors in Chief: Manuele Michelessi, Francesco Oddone