Sensitivity loss in early glaucoma can be mapped to an enlargement of the area of complete spatial summation

Purpose. The area of complete spatial summation (Ricco's area) is the largest stimulus size for which area × intensity is constant at threshold. The authors sought to investigate whether Ricco's area changes in early glaucoma to account for the decreased visual signal/noise ratio that may accompany retinal ganglion cell loss. Methods. Spatial summation functions were measured, and Ricco's area was determined at four 10° retinal locations in 24 patients with early glaucoma (total deviation at test locations, mean, −1.3 dB; range, +2 dB to −8 dB) and 26 age-similar healthy subjects under achromatic and S-cone isolation conditions. Achromatic grating resolution acuity was measured at the same locations to estimate functional ganglion cell density. Results. Ricco's area was enlarged in patients compared with controls for both achromatic (enlarged by: superior field, 0.57 log units, P < 0.01; inferior field, 0.72 log units, P < 0.01) and chromatic (enlarged by: superior field, 0.26 log units, P < 0.01; inferior field, 0.25 log units, P = 0.065) stimuli, with negligible vertical summation curve shifts along the intensity axis. Resolution acuity was significantly reduced in glaucoma patients in both hemifields (P < 0.001). There was a weak, but significant, relationship between Ricco's area and resolution acuity. Conclusions. Enlargement of Ricco's area completely compensates for reduced perimetric sensitivity in early glaucoma to maintain constant threshold at Ricco's area, suggesting an increase in signal pooling in response to ganglion cell loss. The rightward displacement of the spatial summation curve indicates that perimetric stimuli should be capable of modulating in size as well as/instead of contrast, which may boost the glaucoma signal within measurement noise