This document discusses visual field testing methods and interpretation. It describes common visual field tests including confrontation, kinetic perimetry, and static automated perimetry. Normal visual fields subtend approximately 140 degrees monocularly. Automated static perimetry tests like Humphrey and Octopus are now commonly used to evaluate for conditions like glaucoma by testing the central 24 or 30 degrees. Test results are interpreted through gray scale and total deviation plots to identify localized areas of visual field loss and global indices provide an overall measure of sensitivity. Common defects seen in glaucoma include arcuate scotomas and temporal wedges. Neurological field defects can be homonymous or heteronomous depending on the lesion location.

1. Dwight Thibodeaux, OD
THE VISUAL FIELD

2. VISUAL FIELDS
Localized measurement of visual perception
using manual or automated methods to
determine normal status or to evaluate and
track an ocular or neurological disease state.

3. NORMAL FIELDS
• Visual Field - Roughly
140 degrees
monocularly and just
over 180 degrees
binocularly
• Field of Gaze – Over
200 deg
• Field of View – Over

4. COMMON METHODS OF FIELDS
TESTING
• Confrontation –gross target movement - in from
periphery
• Manual kinetic central fields – Tangent screen,
Autoplot
• Microperimetry – Amsler Grid, automated units
• Manual kinetic widefield perimetry – Goldmann
• Automated static perimetry – Computer
algorithm, tester independent
Humphries HFA and FDT/Matrix
Haag-Streit Octopus
Oculus and others

5. HISTORICAL FIELD TESTS

6. CONFRONTATION FIELD TESTING
Technique
Targets

7. GOLDMANN KINETIC FIELD TESTER

8. GOLDMANN KINETIC PERIMETRY

9. OCTOPUS AND OCULUS

10. ZEISS/HUMPHRIES
HUMPHRIES
FIELD ANALYZER (HFA)
FDT and MATRIX

11. TEST STRATEGIES
• Suprathreshold – usually full field - 60
degrees
• 24 degree central field 24-2
• 30 degree central 30-2
• 10 degree 10-2

12. SUPRATHRESHOLD
• Targets set at moderate brightness
(above threshold) with wide field
• Either seen or not seen
• Useful for lid/ptosis evaluation
• Two field tests, taped and untaped

13. THRESHOLDING
• First stimuli presented in each of the 4
quadrants
• Lowered by 3-4 Db until not seen and vise
versa
• Moves to different area and repeats process
• Cloverleaf pattern in poor pt.
management and cooperation

14. SITA / SITA FAST (HFA)
Swedish Interactive Thresholding Algorithm
SITA 50% faster than standard, but 90% accuracy
SITA FAST 70% faster, 80% as accurate

16. FDT/FDP
• Frequency Doubling
Technology (Perimetry)
• For early detection of
glaucoma
• Resistant to blur (Rx) and
pupil size effects

17. MATRIX FDT
• Hybrid of FDT and SAP
• Even more sensitive to early glaucoma
defects
• Too hypersensitive for neuro field testing and
poor for
tracking glaucoma progression
• Best for glaucoma suspects / pre-perimetric
glaucoma

18. SWAP – SHORT WAVELENGTH AUTO
PERIMETRY
• Yellow background and large blue stimulus
on HFA
• Catches early defects in pre-perimetric
glaucoma
• Very time consuming and sensitive to media
opacities
• Matrix now more commonly used

19. 30-2 VS 24-2
• 30-2 = 76 test locations
Most accurate, 0.2 sec.
stimulus vs. 0.25 sec
latency for eye movements
• 24-2 = 54 test locations
Used for the difficult patient

20. HFA 10-2
• 10 deg. central
field for macular
toxicity and end
stage glaucoma
or RP
• Plaquenil –
hydroxychloroqui
ne
• OCT of macula
also part of new
protocol

21. MICROPERIMETRY
• Amsler Grid
• Automated

22. WHAT FIELD IS
INDICATED?
• Glaucoma suspect or pre-perimetric
pt.
• Established glaucoma patient with
field loss
• Neuro patient
• Ptosis patient
• High risk meds patient

23. GLAUCOMA SUSPECT
• Minimal or no nerve head cupping –
Matrix/FDT
• Obvious nerve damage – SITA Standard
30-2
• Difficult patient w/ damage– SITA Fast
24-2

24. ESTABLISHED GLAUCOMA
• SITA Standard 30-2
• Difficult / older patient
SITA Fast 24-2

25. NEURO FIELDS
• SITA Fast 30-2
• Used for unexplained
vision loss or
neuro signs
• Matrix oversensitive

26. PTOSIS OR
BLEPHAROCHALASIS
• Suprathreshold
automated or kinetic
fields
• Wider field to catch
more peripheral
defects

27. HIGH RISK MEDS
SITA 10-2
• For subtle central defects from retinal
toxicity

28. INTERPRETATION
• Quality measures and errors
• Plots
• Glaucoma Hemifield Test
• Global indices

29. QUALITY MEASURES
• Fixation losses – targets blind spot,
need <15%, ? misaligned
• False positives – positive response
when no target is shown, need < 20%
• False negatives – <33%
• Gaze tracker - camera notes eye
movement

31. COMMON ARTIFACTS AND ERRORS
• Ptosis
• Prominent brows
• Lens holder positioning—ring scotoma
• Patient positioning—high FL, ring
scotoma
• False positives based on patient
expectations of stimulus timing

32. GREY SCALE PLOT
• Quickly identifies overall depressions
• Good for patient education
• No comparison for age related normals
• No adjustment for media opacities
• Under represents shallow gen. depression
and overemphasizes midperipheral non-
significant defects

33. TOTAL DEVIATION PLOT
• Graph and
numeric
representation
• Compared to
age-matched
normals

34. PATTERN DEVIATION
PLOT
• Probably the most
important data
• Takes total deviation
and filters out overall
depression (cataracts)
• Looks for focal
damaged areas
pertinent to glaucoma

35. GLOBAL INDICES
• Mean Deviation (MD)
• Positive Standard Deviation (PSD)
• Glaucoma Hemifield Test (GHT)

36. GLOBAL INDICES
• Single number
representations of the
visual field
• Overall guidelines to
help assess the field
• Probability values when
numbers reach
significant levels

37. MEAN DEVIATION (MD)
• Overall level of sensitivity
compared to age-matched
normals
• Not corrected for
generalized depression from
media opacities
• Important for following
diffuse loss in glaucoma
• MD of -2.00 or worse is
suspicious
• Mild damage at <-6
• Moderate at -6 to-12
severe >-12

38. PATTERN STANDARD DEVIATION
(PSD)
• Sensitive measurement of localized loss
• Especially useful in glaucoma
evaluation/progression
• The higher the number, the greater the loss

39. GLAUCOMA HEMIFIELD TEST
GHT
• Compares top and bottom half of field
• General reduction in sensitivity
• Abnormally high sensitivity
• ONL – difference not found in 99% of patients
without glaucoma
• Borderline – difference not found in 97% of normals

40. VISUAL FUNCTION INDEX (VFI) AND
PROGRESSION ANALYSIS
Seen in newer units
VFI similar in meaning to MD
but easier to conceptualize--
100% is normal
75-80% is approaching
significant loss = -6 or worse on
MD

41. COMMON GLAUCOMA
SCOTOMAS
• Arcuate
• Nasal step
• Temporal wedge
• Localized paracentral
• Generalized depression

42. ARCUATE OR NERVE FIBER BUNDLE
DEFECT

43. NASAL STEP

44. LOCALIZED PARACENTRAL SCOTOMAS

45. SECTOR OR WEDGE DEFECTS

46. GENERALIZED DEPRESSION

47. FUNCTIONAL VISION LOSS
• Most common in young girls
• Emotional trauma
• Also called hysterical fields
• Spiral and variable in nature
• Treat with education of parents and
counseling

48. NEURO FIELDS
Unilateral – usually
involves the retina or optic
nerve
Bilateral – involves both
nerves or the optic
chiasm/tract/brain
Homonymous – alike,
same side on both eyes
Heteronomous – different,
opposite sides
Congruous – symmetric in
both eyes
Hemianopia – defect
respects vertical midline

49. MRI CHIASM

50. HOMONYMOUS
• Hemianopsia – homonymous, congruous, points to
cerebral cortex lesion such as stroke
• Quadranopsia or sectoranopsia– cerebral cortex
(congruous) or lateral geniculate nucleus

51. HETERONOMOUS
Hemianopsia-
bitemporal,
congruous- points
to chiasmal lesion
such as a pituitary
tumor
Quadranopsia-
very rare, points to
different area of
chiasm

52. BINOCULAR FIELDS

53. ALTITUDINAL
• Almost always unilateral
• Associated with AION – stroke at the
optic disc

54. CENTRAL SCOTOMA
• More commonly unilateral
as in:
optic neuritis
macular degeneration
early AION, cerebro-vascular
blood loss
retinal dystrophy
Bilateral – toxic, nutritional, heriditary optic neuropathy
and
maculopathy

55. QUESTIONS?
DRTHIB@MSN.COM