VISUAL FIELD TESTING
Dr. Gurkiran Kaur
Third year Junior Resident
Department of Ophthalmology
King Georges Medical University Lucknow
Normal visual field
● Traquair’s “island of vision in a sea of darkness.”
Visual sensitivity increases from the peripheral boundary of vision to a peak
at the fovea
● “Hill of vision”
3D representation of retinal light sensitivity and is dependent on the state of
retinal adaptation
● The greatest packing density of cones occurs at the fovea(~16,000 cones/deg)
and decreases sharply towards the retinal periphery(~300 cones/deg)
The normal VF extends 60 degrees superiorly and naslly,70 degrees inferiorly
and ~100 degrees temporally
Focal disturbance: physiologic blind spot
Centered at 15°on the temporal meridian
Horizontal width of 6–10°
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Extends radially 15–20° on either side of the vertical meridian
Effect of Aging on Normal Visual Field
The hill of vision reduces in height and its slopes become steeper
Normal decline approximately 0.7 dB per decade
Reason :
● changes in the ocular media,
● decrease in the absorbance efficiency of photopigments
● neural losses in the retina
PERIMETRY
The measurement of the hill of vision in terms of patient’s differential light
sensitivity across the visual field
TYPES:-
BASED ON METHOD
1. MANUAL
Operator presents each target, monitor the patient’s fixation, and records the
patient’s response.
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ADVANTAGES:-
● As the operator monitors fixation, responses made when the patient was not
looking straight ahead can be discarded
● As operator chooses the locations to probe, each test can be groomed to the
type of problem suspected from history or confrontation testing.
Highly dependent on the skill and judgment of the observer.
METHODS:
a. Confrontation
A target moved along an imaginary flat plane between, and perpendicular to,
the gaze of the patient and the practitioner.
Other tests: the presentation of two red targets to the hemifields to find out
whether one of the targets is desaturated
b. Gross Perimetry
A handheld target held at a constant distance from pts eye and is brought in
an arc from beyond their VF boundary. This allows pt to announce when the
target is first seen
c. Amsler Chart
Assess the quality of the central field of vision.
A square white grid printed on a dull black background, comprising of 20
rows and 20 columns of smaller squares
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The patient views the chart at 28cm where each square subtends an angle of 1
degree at the retina
Indications-
● Macular disturbance seen on ophthalmoscopy
● Reduction of acuity through a pinhole
● Symptoms of central visual distortion
● Systemic disease/drugs which may predispose to a maculopathy
2. AUTOMATED
More highly standardized and provides a sophisticated statistical analysis that is
grounded in age-related normative data
Provides estimates of the reliability and response bias of the patient
It requires less skill and time from the practitioner but more attention from the
patient
Assessment
Involves four areas:
1. Setting up the patient
Comfortably and correctly aligned with the perimeter
Any postural discomfort will influence patient vigilance and therefore VF
outcome
Patient occludes one eye
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The centre of the pupil should be positioned in the centre of the cross target
present on the video image
2. Giving refractive correction
Optical defocus reduces the luminance of the stimulus on the retina and increases
the area of the stimulus, circularly in spherical defocus and elliptically in the case
of cylindrical defocus.
● All cylinders > 1 D should be incorporated into the correction.
● Presbyopic corrections should be incorporated, suitable for the viewing
distance
● Bifocal lenses avoided as optical defocus is induced by the distance portion
and prismatic jump induced by the segment, resulting in blind spots and
displacement of stimuli.
3. Preparing the patient
Patient fixates on fixed target.
Should be explained the procedure
In cases of central scotoma, e.g. in macular degeneration, the patient will not
be able to fixate the default target. In these cases, good fixation can be
obtained by instructing the patient to fixate the projected center of the cross.
Pupil size and shape determines retinal illumination, and consequently can
influence visual field sensitivity.
4. Monitoring the patient during the test
a. Fixation Monitoring: Physical method/ HJ method
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b. Gaze tracking
c. Fixation Losses
d. Patient Fatigue
BASED ON STIMULUS PRESENTATION
1. Kinetic
Moving stimulus detected more readily in the periphery because of successive lateral
spatial summation.
The optimal speed of movement of a kinetic stimulus is 4° per second
Shallow focal loss in the visual field missed
USES
● Patients with profound visual field loss as it can rapidly define areas of
residual function and areas in the visual field with deep focal loss.
● Fastest method for delineating the limits of the visual field.
2. Static
The size of the stimulus is constant and varied in intensity until the patient is just
able to detect it
THRESHOLD : The minimum light energy necessary to evoke a visual response
that the observer can detect the stimulus 50% of the time
The threshold is expressed in terms of sensitivity (measured in dB), which is the
reciprocal of the threshold.
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STATIC PERIMETRY
KINETIC PERIMETRY
Measures visual field by plotting Measures sensitivity of each retinal point
isopters
Stimulus moves from non seeing to Stimulus stationary, but increases in
seeing area luminance until seen
Stimulus size can be varied Constant
BASED ON THRESHOLD STRATEGIES
1. Suprathreshold
2. Full Threshold
3. FASTPAC
4. SITA
▪ SITA standard
▪ SITA Fast
▪ SITA Faster
ANALYSIS OF PERIMETRY
1. Numeric data
Threshold values
2. Color Scale
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Banded in 5db groupings
3. Probability Plots
Total and pattern deviation plots
4. Global Indices
Mean sensitivity, Mean deviation, Pattern standard deviation
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INTERPRETING HVF PRINTOUT
Patient data & Test data
ZONE 1
ZONE 2 Foveal threshold & Reliability indices
ZONE 3 Grayscale
ZONE 4 Patient’s raw data
ZONE 5 Total Deviation plot
ZONE 6 Pattern deviation plot
ZONE 7 Global indices
ZONE 8 Glaucoma Hemifield test
ZONE 9 Eyetracking
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VISUAL FIELD DEFECTS
1. Glaucoma
DIFFUSE VISUAL FIELD LOSS
● one of the earliest changes
● mild, generalized reduction in sensitivity across the visual field due to diffuse
loss of retinal nerve fibers throughout the optic nerve
● only clinically detectable using automated full threshold static perimetry
FOCAL VISUAL FIELD LOSS
Small areas of focal loss in the paracentral visual field
● Most commonly, in the superior nasal aspect of the visual field
● As glaucoma progresses, leads to the formation of arcuate scotomas
● If symmetrical, form a ring scotoma
● In the end stages of glaucoma only a small circular area of normal visual field
sensitivity remains around fixation
GHT
● Ten anatomical sectors in the visual field are superimposed on the Program
30-2 test grid, selected according to the normal arrangement of retinal nerve
fibers
● Five sectors in the upper hemifield mirror five sectors in the inferior field
Within each sector, the sum of the probability scores is calculated and the
difference compared to the mirror image sector.
2. Neurological Disorders
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● One eye only – most likely pre-chiasmal
● Heteronymous – chiasmal
● Homonymous – post-chiasmal
● Pre-LGN – pupil reflexes affected
OTHER PERIMETRY TECHNIQUES
1. Tendency oriented
2. Spatial grid
3. SWAP
4. Frequency Doubled
5. Flicker perimetry
6. Motion perimetry
7. Microperimetry
References-
• ‘Eye Essentials: Visual Fields’, Robert Cubbige, Elsevier Publication
• Step by step Visual Field Examination AK Gupta, Reena M Choudhry, Charu
Tandon, Jaypee publishers
• [Link]
• [Link]
• [Link]/article /visual-field-testing-for-glaucoma-a-practical-guide/
• [Link]
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