2. SCOPE
Introduction
VEP stimuli
Types of VEP
Equipments required
Prerequisites
Recording of VEP
Properties of VEP waveform
Interpretation
Clinical applications
3. VISUAL EVOKED POTENTIAL
EEG is a record of the electrical activity of the brain,
obtained by placing surface electrodes on the scalp
VEP is an 'evoked' electrophysiological potential
recorded from scalp in response to visual stimuli
It assess the integrity of the visual pathways from the
optic nerve to the occipital cortex
4. ANATOMIC BASIS OF VEP
VEP grossly over-represent
the macular region primarily
because anatomically:
• Macular fibers project to
the occipital lobe cortex,
and those from the
peripheral retina project
deeper within the calcarine
fissure
• Also, over the course of
the visual pathway, the
macular field gets
‘amplified’ as it reaches the
cortex
5. VEP STIMULI
VEP can be evoked by either a flash of light or a
pattern
Flash Stimuli
• The flash VEP is elicited by
flashes of light produced by a
xenon arc photo stimulator
• Occipital cortex is relatively
insensitive to flash
6. Pattern Stimuli
• These are presented in a checker-board pattern
• ‘Pattern onset offset‘ form wherein the pattern is
shown for a brief period and then replaced with a
blank screen (of the same intensity)
• ‘Pattern reversal’ type wherein the black and white
checks reverse their orientation
• Luminance contamination: The evoked potential
should be in response only to the changing pattern
and not due to a change in light intensity (brightness)
Therefore, the average luminance must be kept
constant throughout the test
7. TYPES OF VEP
Flash VEP
• Less commonly used
• Used in uncooperative
and unconscious patients
Pattern VEP
• Most commonly used in
clinical practice.
Chromatic patterned stimuli
• Helpful in detecting color
blindness.
8. TRANSIENT AND STEADY-STATE
VEP
If the visual stimulus is intermittent, thus allowing the
brain to recover its resting state in between, then the
VEP obtained is called transient VEP.
• Transient VEP is used for all practical purposes.
If however, the stimulus is projected faster so that the
brain does not regain its resting state, a sinusoidal
waveform called steady-state VEP is obtained.
• Not used routinely due to inferior information on
latency or amplitude components.
9.
10. FLASH VEP
Flash Response to diffusely flashing light stimulus that
subtends a visual field of 20 degrees
It is performed in a dimly illuminated room
Cruder response than pattern VEP
Merely indicates that light has been perceived by cortex
Indications - media haze, infants, poor pt cooperation
11. PATTERN REVERSAL VEP
Response to a patterned stimulus - checkerboard or
square and sine wave gratings
Frequency of gratings is described in CPD - cycles
per degree
For check pattern visual angle subtended by a single
check is used
Preferred technique for most clinical purposes, gives
an estimate of form sense and thus visual acuity
12. PATTERN ONSET/OFFSET VEP
A pattern is abruptly exchanged with an
equiilluminant diffuse background
More intersubject variability than pattern reversal VEP
Useful in detection of pts with poor fixation,
malingering, deliberate defocusing, pts with nystagmus
13. EQUIPMENTS REQUIRED
Visual stimulus producing device
Scalp electrodes
Amplifier
Computer and read out systems
14. PREREQUISITES
There should be no distracting sound or light waves
Pattern and flash must both be done in all patients as
pattern cannot be detected in pts with media opacities
Pattern VEP followed by flash VEP
Procedure is significantly affected by eccentric
fixation, excessive blinking of eyes and partial closure
of eyes
15. RECORDING OF THE VEP
Recorded monocularly with undilated pupils
Refractive correction and in a relaxed position at the
calibrated viewing distance (1m distance from monitor)
The pupillary size should be noted for each
evaluation
While monocular stimulation is standard; in children
or other special groups, binocular stimulation may be
used to assess visual pathway conduction from either
eye
While performing flash VEP, a mechanical patch
should be applied over the unstimulated eye
16. PROPERTIES OF THE VEP
Amplitude :
• It is the height of the wave (vertical) measured in
microvolts from the preceding trough
• Absolute amplitude is difficult to compare because
of the large variation between normal persons and
variations in sensitivities of the recording equipment
• Relative amplitude (difference between the two
eyes) is more sensitive when looking for unilateral or
asymmetric disease
• In general, absolute amplitude of P100 less than
05 microvolts is abnormal
17.
18. Latency :
• Measured in milliseconds, it is the delay between
the stimulus presentation and the peak of the wave
in question.
• Latency shows much less variation between
subjects
• However, it is also affected by a number of
factors, including pupil size, refractive error, age and
stimulus factors (pattern size, luminance and
contrast)
• Latency of P100 wave should not exceed 110 ms
in patients under the age of 60 years.
19.
20. Waveform :
• Age dependent and are standardized for a
population between 20 - 60 years of age.
• In a standard wave pattern, the time from stimulus
onset to the maximum positive or negative excursion
of the VEP is recorded as "peak time“
• The flash VEP pattern comprises a series of positive
and negative deflections, with a peak time varying
between 30 ms to 300 ms, the most robust peaks
being the N2 and the P2 peaks at about 90 ms and
120 ms peak time respectively
21. • Pattern reversal VEP waveforms comprise the N75,
P100 and N135 peaks (Fig. A)
• Standard pattern onset-offset VEPs demonstrate
three main peaks in adults; the C1 positive peak at
about 75 ms, the C2 negative peak at about 125 ms
and C3, another positive peak at about 150 ms (Fig. B)
22. FACTORS INFLUENCING VEP
Size of stimulus - Decrease in size of stimulus increases
amplitude of VEP
Position of electrodes on scalp
Age - amplitude decreases with age
Gender - P100 latency is longer in adult males and
mean amplitude is greater in females
Pupil size - Pupillary constriction increase P100 latency
which is attributed to decreased area of retinal
illumination
Eye movements - reduces the amplitude of P100 but
latency is not affected
Attention of patient - If subject looks to side of stimulus,
there is rapid fall in size of response
23. INTERPRETATION
Each eye projects to B/L occipital cortex via optic
chiasma
Unilateral VEP abnormality - Anterior visual pathway
lesion (pre chiasmal lesion)
Bilateral VEP abnormality - No localizing value
Latency prolongation
• P 100 Latency prolongation > 3 SD or interocular
latency difference > 10 m sec is significant
• Prolonged P 100 latency - demyelinating lesions,
retinopathies and glaucoma.
24. Amplitude reduction
• Amplitude of P 100 shows wide individual variation
• Hence, Inter ocular amplitude ratio is used to
detect abnormalities
• Inter ocular P 100 amplitude ratio > 2 is significant
• Reduced amplitude indicates axonal lesions like
AION
Combined latency & amplitude abnormalities
• Optic nerve compression produce results in
segmental demyelination and axonal loss
• Hence it produces combined latency and
amplitude abnormalities
26. PATTERN VEP
Optic neuritis and multiple sclerosis (MS):
• Characteristically shows a delayed P100 latency
• Finding persists even after recovery of visual acuity,
hence, it can be useful in confirming a previous attack of
optic neuritis
• However, it may not be able to delineate a fresh attack
• Patients with MS but without a history or clinical
features of optic nerve involvement can show abnormal
VEP responses to pattern stimulation, suggesting
subclinical visual pathway involvement.
28. Nonarteritic anterior ischemic optic neuropathy
(NAAION):
• Typically shows reduced wave amplitude but
latency is not significantly delayed
• VEP in the clinically uninvolved eye is invariably
normal
Compressive lesions:
• Shows prolonged latency at an early stage, though
not as much as in optic neuritis
• Much higher incidence of waveform abnormalities
than in patients with demyelinating disease
Functional visual loss:
• Distinguishes between organic and functional
visual loss
• A normal pattern VEP establishes the presence of
an intact visual pathway
30. Patients with motor disorders:
• Such patients may appear visually impaired
because the eyes cannot track a moving target.
• in children with cerebral palsy, is a preferred
modality, but may be difficult to perform it because of
seizure activity, wandering eye movements or
depressed cortical activity due to anticonvulsants.
Nystagmus:
• Use of horizontal gratings produces less blur.
• Pattern onset preferred rather than pattern reversal
provide more accurate information.
31. THANK YOU
Children with neurofibromatosis type 1 are vulnerable to
development of optic nerve glioma
VEP can be a more sensitive and cost effective test to
follow the progress of nerve pathology than MRI tests alone
32. Malingering and Hysteria:
• Patients with Hysterical Blindness.
• VEP remains normal with vision as low as 1/60.
• VEP can be enhanced by using large fields, large
checks and binocular vision.
During Orbital or Neurosurgical Procedures:
• Continuous record of optic nerve function in form
of VEP to prevent inadvertent damage to the nerve
during surgical manipulation
33. FLASH VEP
Can be performed in shorter time
No need for active patient participation
Used in adults and infants with dense media
opacities to test the visual pathway integrity
• A good correlation between VEP prediction and
actual postoperative visual acuity has been seen in
patients with dense cataracts.
Used as a prognostic tool prior to vitrectomy in
diabetic vitreous hemorrhage
To evaluate the central nervous system in high-risk
neonates, especially those born prematurely, with
intraventricular hemorrhage, or hydrocephalus.
34. MULTIFOCAL VEP
mfVEP recorded with the same equipment as for mfERG
VEPs recorded simultaneously from multiple regions of
the visual field
Visual field divided into 60 sectors, each having 16
checks (8 black and 8 white)
Sectors and checks are scaled differently (peripheral
sectors larger) so that they are all of approximately equal
effectiveness for cortical stimulation.
Pseudo-random sequences and a software algorithm
allow the on-board computer to rapidly extract information
simultaneously from each of the stimulated sectors.
mfVEP provides a probability plot like automated
perimeters
35. Used to detect small abnormalities in visual signal
transmission from centric and eccentric field and provides
a topographical display of these deficits
To rule out non-organic visual loss
To diagnose and follow-up patients of optic neuritis and
multiple sclerosis
To confirm unreliable or questionable visual field
examinations
36. MULTICHANNEL VEP
This technique uses multiple active (parasagittal)
electrodes
This technique provides localizing value
Chiasmal lesions show a crossed asymmetry, i.e.
findings of one eye show an asymmetrical distribution that
is reversed when the other eye is stimulated.
Retrochiasmal lesions show uncrossed asymmetry,
wherein findings of each eye show an asymmetrical
distribution across the hemispheres that is similar when
either eye is stimulated