Slide

Slide
2

Slide
3 Visual Fields
Learning outcomes
Know-how and skill
• Show proficiency in performing a
structured examination of visual fields by
confrontation using both static and
kinetic techniques to detect either ocular
or visual pathway-related defects.
• Recognize any abnormal signs and apply
their knowledge when determining their
possible causes.
Slide
4 Visual Fields
Learning outcomes
Competence
• Adopt an empathic and holistic
approach to patient assessment.
• Extrapolate from any abnormal signs
the key relevant features to form a
differential diagnosis with appropriate
management strategies.

Slide Please write your answers on

5 Visual Fields a card (to be provided by
Background Knowledge Probe tutor) before reviewing the
1. Explain what the term ‘blind spot’ refers to rest of the slides. The idea is
in terms of the eye’s visual fields. to get a feel for what students
2. What is the classic visual field defect already know on this topic
associated with glaucoma?
and which areas need more
3. List 3 causes of an altitudinal visual field
defect. time during the face-to-face
4. What type of field defect does a pituitary tutorials. You should hand
tumour cause? your answers in at the start of
5. What part of the visual pathway is the tutorial, but don’t put your
associated with a macular sparing left name on them. For the
homonymous hemianopia?
exercise to be worthwhile,
your answers should be
honest and anonymous, and
will not be marked.

Examination of Visual
Fields by
Slide
6
Confrontation:
Introduction/explanation to
subject.

Get subject to remove their glasses.

Sit directly in front of the subject,

approx. 1m apart (e.g. having a
small gap between examiner’s and
subject’s knees), and at the same
eye level.

Ask subject to occlude their right

eye.

Static: test for gross defects /

central vision by asking subject is
any part of examiner’s face missing
or distorted.

Static: test finger counting in all 4

quadrants of visual field for
subject’s right eye, ensuring that
the fingers are presented
adequately in each quadrant and
do not straddle two quadrants at
the same time.

Static: comparison of hemifields -

test finger counting in both
hemifields for right eye separately
and then simultaneously to test for
neglect (may indicate parietal lobe
lesion).

Repeat for left eye.

Kinetic: ask subject to cover their

right eye again, cover your own
(opposite) eye, and establish that
they can see target being used
(testing central vision).

Kinetic: bring target from periphery

(e.g. white hat pin or wiggling
finger) testing all four quadrants of
visual field of right eye, and
ensuring target is equidistant
between examiner and subject –
keep moving towards centre to
detect any paracentral defects.

Repeat for left eye

See Youtube link below

demonstrating how to test if the
blind spot is enlarged, although this
will not need to be performed for
the clinical skills exam.

There is a useful description of

visual field testing technique
available on Medscape:

http://emedicine.medscape.com/ar
ticle/2094663-
technique#aw2aab6b4b1aa

There are also a number of useful

videos available on Youtube
demonstrating confrontation visual
field testing which may help you to
visualize and recall the above
process more easily, for example:

https://www.youtube.com/watch?
v=2-9FVywV2j4
Slide
Case Report:
7 77 yr old diabetic complaining of vague visual disturbance, with
hallucinations along the right hand side of her vision

Slide Please write your answers on

8 Case Report Questions a card before reviewing the
rest of the slides. You should
1. Describe what type of visual field defect is hand your answers in at the
shown in the previous slide? start of the tutorial, but don’t
2. What part of the visual pathway is put your name on them. For
associated with this type of visual loss?
the exercise to be worthwhile,
3. What type of lesion is most likely to have
caused this type of visual field defect? your answers should be
4. What is the name given to the phenomenon honest and anonymous, and
of experiencing visual hallucinations in will not be marked.
association with visual loss?

Slide Field of vision:

9 Visual Fields - Definitions Portion of space which can be
seen by the eye and is
• Field of vision bounded by nose, eyebrow,
cheek.
• Scotoma
Scotoma:
• Blind spot Area of absent or depressed
• Assessment - Perimetry vision within the field.
– Static Blind spot:
– Kinetic Optic disc has no
• confrontational VF’s – red vs white target photoreceptors and results in
an absolute scotoma temporal
to fixation.
Kinetic perimetry:
Moving target (Goldmann).
Target brought in from
periphery. White pin for
peripheral field, red target
more sensitive for cenrtal 30°.
Static perimetry:
Fixed spots of light of varying
 intensity (Humphreys). In
each quadrant ask pt.
whether 1 or 2 fingers seen.
Check each eye separately
first, but important to check
eyes simultaneously as well.

Slide Diagrammatic representation

10 of normal visual field of left
eye showing blind spot
temporal to fixation.

Slide
11 Humphrey Visual Field Analyzer
Slide Slide curtesy of Alcon’s
Glaucoma Slide Resource
12 Visual field examination – perimetry
• Testing of visual field is
mandatory in glaucoma
assessment and management in
order to define the state of optic
nerve function and visual
impairment.
• All patients with glaucoma or
suspected glaucoma should
undergo frequent visual field
examinations.
•
Standard automated perimetry
Mild loss of visual field Severe loss of visual field (SAP) is the preferred technique
for evaluating the visual field in
glaucoma subjects.
• Characteristics of glaucomatous
visual field defects include:
• Asymmetrical across
horizontal midline in
early/moderate cases
• Located in mid-
periphery, 5–25 degrees
from fixation, in
early/moderate cases
• Reproducible
• Not attributable to other
pathology
• Clustered in
neighbouring test points
(localised)
• Defect should correlate with the
appearance of the optic disc and
neighbourhood.

Slide See text book for diagram of

13 Visual Pathway visual pathway.

1. Photoreceptors.
2. Bipolar cells.
3. Ganglion cells – axon passes thro’
optic nerve – chiasm – optic tract –
lateral geniculate body – synapses
with:
4. Neurone – optic radiation – visual
cortex.
Slide
14 Clinical features relating to
site of visual pathway lesion
Eye & Optic Nerve:
Field loss:
• Visual loss in one eye.
• Central loss suggests macular or optic nerve
disease.
• Peripheral loss suggests retinal disease or
disease of optic nerve head.
• Altitudinal field loss (see slides 16 & 17) implies
anterior ischaemic optic neuropathy, but can also
be due to retinal detachment, hemispherical retinal
vein or artery occlusion, or advanced glaucoma.
• NB Glaucomatous field loss – arcuate scotoma
(see upcoming slides), central vision spared til
late.

Slide Diagrammatic representation

15 of visual field showing central
field loss, most likely due to
macular pathology.

Slide Diagrammatic representation

16 of visual field showing
centrocaecal scotoma where
there is central field loss
combined with enlarged blind
spot, most likely related to
optic nerve pathology.
Slide Anterior ischaemic optic
17 AION – swollen disc, neuropathy: the superior half
hypoflourescence seen on of the disc is especially
hypoflourescent, which
FFA hypoflourescence
suggests hypoperfusion with
respect to blood carrying
flourescein dye to this area –
ischaemia of this superior part
of the disc will result in a
corresponding visual field
defect. Which part of the field
do you think will be
particularly affected?

Slide Inferior altitudinal defect in

18 keeping with ischaemia
particularly of superior part of
disc in previous slide.

Slide Advanced glaucomatous optic

19 Glaucoma disc cupping in both eyes.
With the inferior neuroretinal
rim of the discs being
especially thin, what part of
the field is going to be most
affected? (see next slide for
answer)
Slide Advanced superior arcuate
20 scotoma in keeping with
thinned inferior neuroretinal
rim seen in previous slide.

Slide Glaucomatous field loss with

21 inferior nasal step – difference
in the sensitivity above and
below the horizontal midline in
the nasal field (common
finding, usually assoc. with
other defects).

Slide Visual field of a patient showing superior Some arcuate scotomas can
22 arcuate scotoma, who had a cup-to-disc affect one half of the visual
ratio of 0.5, and very thin inf. NRR field more than the other. The
defect in this slide is similar to
the altitudinal defect seen in
cases of AION. However, the
degree of optic disc cupping
with thinning of the inferior
neuroretinal rim (NRR) helps
differentiate the two
conditions.
Slide Visual field of a patient showing Small central spared island of
23 extensive scotoma, who had a cup-to- vision means that visual
disc ratio of 0.9, and very thin NRR acuity can remain excellent
even in advanced cases of
glaucoma, demonstrating how
the condition can present very
late unless picked up early
through routine screening.

Slide
24 Clinical features relating to
site of visual pathway lesion
Optic Chiasm:
Field loss:
• Bitemporal hemianopia (frequently asymmetrical).
• Colour desaturation across vertical midline is earliest sign.
• May present late, until central vision affected from pressure on
fibres serving macula.
• Eventual complete blindness.

Causes:
• Pituitary adenoma (usually chromophobe – superotemporal
field initially).
• Craniopharyngioma (from vestigial remnants of Rathke pouch
along pituitary stalk - inferotemporal field initially).
• Meningioma (typically compresses junction of optic chiasm
with optic nerve – ipsilateral central scotoma, contralateral
upper temporal defect).
• Aneurysms (ICA)/vascular accidents/trauma less common
cause.

Slide Diagrammatic representation

25 of visual fields showing
bitemporal hemianopia, most
likely due to pituitary
adenoma.
Slide
26 Clinical features relating to
site of visual pathway lesion
Optic Tract:
Field loss:
• Contralateral homonymous hemianopia.
• Incongruous, as nerve fibres originating
from corresponding retinal elements not
closely aligned.

Causes:
• Uncommon.
• Posterior extensions of pituitary tumours.

Slide Diagrammatic representation

27 of visual fields showing left
incongruous homonymous
hemianopia.

Slide ‘optic radiation visual field

28 Clinical features relating to
defects are the PITS’:
site of visual pathway lesion
Optic Radiation: Parietal lobe = Inferior field
Field loss:
• Temporal radiations: contralateral homonymous superior
quadrantanopia (‘pie in the sky’). defects, Temporal lobe =
• Anterior parietal radiations: contralateral homonymous inferior
quadrantanopia (‘pie on the floor’).
• Main radiations (deep in parietal lobe): complete homonymous Superior field defects
hemianopia.
• Congruous (increasing congruity as the optic radiation passes
posteriorly, as nerve fibres from corresponding retinal elements lie
progressively closer together).

Causes:
• Tumours.
• Vascular insults.
• Basal meningitis.
• Aneurysms.
• Abscesses.
• Trauma.
• Migraine.
Slide Binocular visual field showing
29
L
R left inferior homonymous
quadrantanopia. Where is the
likely site of the
corresponding visual pathway
lesion? Is this patient allowed
to drive with this defect? (see
http://www.rsa.ie/Documents/
Both
eyes
Licensed%20Drivers/Eyesight
_Report_D_502_Form.pdf).

Slide Diagrammatic representation

30 of visual fields showing left
congruous homonymous
hemianopia.

Slide Diagrammatic representation

31 of visual fields showing
incomplete left congruous
homonymous hemianopia.
Slide
32 Clinical features relating to
site of visual pathway lesion
Visual Cortex:
Field loss:
• Anterior visual cortex where peripheral vision
represented (supplied by posterior cerebral
artery): macular sparing congruous homonymous
hemianopia.
• Macula cortex (supplied by middle cerebral artery):
congruous homonymous macular defects.

Causes:
• Vascular lesions.
• Migraine.
• Trauma.
• Tumours.

Slide
33 Case Report Answers
To be discussed in face-to-face tutorial

Slide Please write your answers on

34 Minute Paper the same card that you used
in answering the background
• What do you think is the most knowledge probe.
important clinical finding not to miss
when it comes to visual field
assessment that you now understand
well, that you didn’t know before?
• What aspect of visual field assessment
or theory do you still find confusing or
least clear?
Slide
35 It may be more comfortable for
the patient if you test static for
the right eye and then left eye,
followed by kinetic for the right
eye then left eye. Otherwise
they may become tired from
covering the same eye for a
prolonged period of time.