1.

Global Indices. In the lower-right corner of the single fi eld printout, STATPAC displays two global
indices, which describe the entire visual fi eld using averaged numeric values:

1. MD (mean deviation) is an average value of overall deviation from the expected results within the
same age group of normal visual fi elds. This value refl ects the average height of the entire hill of
vision. Negative values represent depression. MD is relatively insensitive to localized defects and is
strongly affected by generalized decrease of sensitivity, such as cataracts.

2. PSD (pattern standard deviation) represents the unevenness of the surface of the hill of vision. It is
calculated by taking a location-weighted standard deviation of all the threshold values. PSD is
insensitive to the overall average height and is strongly affected by localized defects.

Global indices generally correlate with visual fi eld shape. For example, uniform generalized
depression, as seen in cataract, tends to produce an increasingly negative MD. A small localized
scotoma may have only slightly decreased MD and a high PSD (Figure 3-20). A dense moderate-size
scotoma typically produces an elevation in both MD and PSD (Figure 3-21).
2.

GLOBAL INDICES

Three summary indices of visual field status—VFI, MD, and PSD-appear on the SFA printout.

VFI (Visual Field Index) is a recently developed staging index, designed to be less affected by cataract
and also to provide improved correspondence to ganglion cell loss compared to MD.60 VFI is
approximately 100% in normal fields and approaches 0% in perimetrically blind fields.

MD (Mean Deviation) shows how much on average the whole field departs from age-normal, and is
a center-weighted average of the decibel deviations shown in the Total Deviation plot. MD is
primarily used to stage visual field loss and as a metric for rate of change over time. MD is
approximately 0 dB in normal fields and -30 dB to -35 dB in extreme visual field loss, depending upon
patient age and test program.

PSD (Pattern Standard Deviation) reflects irregularities in the field, such as those caused by localized
field defects. PSD is small, close to zero, both in normality and in blindness, and peaks at moderate
levels of localized field loss; because of this nonlin- ear behavior, PSD should not be used as a staging
or progression index.

REABILITIY
3.

2.1.3. GLOBAL INDICES

Global indices are meant to provide some grand summary that captures something about the field in
a single number. While this may seem a bit futile, these indices can be useful in sequential follow-up.
All are printed as sensitivity measures in decibels, along with the (p-value) probability that these are
abnormal.

1. Mean deviation (MD): This is simply the mean of all the values in the total deviation map.
Obviously, the deviation in the localized defects common to neuro-ophthalmologic problems will be
diluted by the lack of deviation in regions without defects. On the other hand, MD will be strongly
affected by refractive factors that globally depress sensitivity, such as cataracts or incorrect
refractive correction. Nevertheless, MD can be moderately useful in the following the change in a
field over time, as long as global refractive issues are taken into account. The latter should be
obvious from the total deviation probability plots.

2. Pattern standard deviation (PSD): This is the mean of the values in the pattern deviation plot. PSD
advances on mean deviation in that the effects of global depression should be filtered out.
4.

ZONE 9—GLOBAL INDICES

There are three basic concepts that help to understand the usefulness of visual field indices or global
indices:
1. Visual field loss tends to occur either in a diffuse pattern or a localized pattern or a combination of
the two;
2. It is clinically useful to determine which of the two components (diffuse or localized loss) is
changing more rapidly; and
3. If the information regarding the amount of diffuse vs localized loss and the relative rate of change
of each can be quantified and then reduced to a simple number, the clinician can assess valuable
information about each of these parameters at a glance.
The basic global field indices:
1. Mean deviations (MD)
2. Pattern standard deviation (PSD)

To understand global indices one should have a clear concept of the hill of vision. In the normal
visual field the fovea is the highest retinal sensitivity point. So the peak of the hill of vision is
represented by the fovea and retinal sensitivity decreases as it moves away from the center (fovea)
to the periphery. This drop of sensitivity from center to periphery gives characteristic shape and
contour to the hill of vision. The slope of normal hill of vision is quite smooth. The normal shape and
height of hill of vision are shown in the figure. The most important points to be focussed are the
height of hill of vision and the contour of the hill of vision. The change in the retinal sensitivity will
affect either the height of hill of vision or the smooth contour of the hill of vision or both.

To express the height of hill of vision and the contour of hill of vision the global indices are developed.
The mean deviation index expresses the change in the height of hill of vision and the PSD expresses
the change in smoothness of the contour of the hill of vision

MEAN DEVIATION INDEX

The mean deviation index signifies the average of overall severity of field loss. Actually it is the
average of all the numbers shown of the total deviation numerical plot except the two points in the
area of the blind spot. The deviation from normal at each point is weighed according to the variance
of the normal values at that location. Thus points with low variance-that is, closer to fixation-affect
the MD value more than do the more eccentric points, which have a higher variance. The mean
deviation is expressed in dB units with P value. The positive value indicates that the patient’s overall
sensitivity is better than normal observer whereas negative value indicates that the patient’s overall
sensitivity is worse than the average normal individual. The sensitivity profile (‘hill of vision”) of the
normal visual field is depicted by the solid diagonal lines and a general depression of visual field
sensitivity is depicted by the broken line. The mean deviation (MD) is the amount of visual field
depression relative to normal, as indicated by the length of the arrows. Usually, the loss of sensitivity
is not exactly the same at all locations, in which case the MD is the average amount of loss. If MD is
lower than that found in 10% of the normal subjects in the perimeter’s database, a significant level is
printed (P <10% ), making it unnecessary to memorize the corresponding limits of normality. No
probability statement is given for supernormal findings.
Role of MD index in the diagnosis of early glaucoma: Rarely mean deviation falls outside the normal
range by virtue of glaucoma without first producing one of the diagnostic signs of a localized defect.
If we suspect glaucoma on the basis of asymmetry of intraocular pressure or of disk cupping, the
difference of mean deviation index between both the eyes should be taken as a serious clue in
confirming the diagnosis of glaucoma. (1) 2 dB difference of mean deviation index between the two
eyes. (2) An average 1.5 dB difference must be maintained between the two eyes on two
consecutive tests. (3) An average difference of 1 dB must be maintained between the two eyes on
four consecutive tests. Note that -1 dB difference of MD index between the two eyes in 24 -2 point
pattern is equal to total difference of 52 dB between the two eyes. In other words the 52 dB loss of
retinal sensitivity becomes -1dB when it is expressed in terms of MD index in 24-2 point pattern.

Role of MD index in the follow up tests: The most important index to assess field progression is MD
index. The expected change in MD index per year is -0.08 dB normal. The increase in MD>0.08 dB
per year should be considered as abnormal. Remember that even a small change in MD index in a
case of localized field defect is significant. Confirm that the increase in MD index is not due to the
following causes- Improper refractive error correction, pupil size high false negative errors, different
point patterns and different testing strategies for the comparing tests. If the increase in MD index is
not due to any of the above factors then only we have to analyze MD index raw data and probability
plots for glaucoma progression.

The MD index is usually high in generalized field defects (uniform generalized and irregular
generalized field defects) and the value of MD index in localized field defect depends on the extent
and depth of the field defect.

PATTERN STANDARD DEVIATION

Pattern standard deviation (PSD) is an index to express dissimilar deviation values in the total
deviation numerical plot or in other words to express the contour of hill of vision whether it is
smooth or rough. The roughness of hill of vision can be either due to loss of sensitivity or due to the
the measured sensitivity being better than normal values. So PSD does not carry either (+) or (-) sign
infront of it. It will be a simple number. If the roughness of the slope is not significant, PSD will be a
simple number without P value. If the deviation of the slope is significant it will be represented by P
value, So PSD with significant P value indicates the numbers in the total deviation numerical plot
(TDNP) are not similar to each other.

PSD is an index developed to pick up dissimilar deviation values in total deviation numerical plot. For
all practical purposes it is an index to pick up localized scotoma or scotomas which is an early sign to
diagnose glaucoma. So PSD helps to diagnose glaucoma at an early stage. Please remember that
once glaucoma is diagnosed, PSD has very minimal role in the management of glaucoma. PSD with
significant P value indicates the presence of localized field defect which can either be a pure
localized field defect or a localized field defect in generalized depression (irregular generalized
depression).

CORRELATION BETWEEN PSD VALUE AND CONTOUR OF HILL OF VISION

As you know the PSD is developed to express the irregular loss of retinal sensitivity - higher the
irregularity in the loss of sensitivity, higher the PSD value. When there is a localized field defect, the
contour of hill of vision is irregular without affecting the height of hill of vision (high PSD value).
When there is irregular generalized field defect, the height of hill of vision is decreased and the
contour of hill of vision is irregular (high mean deviation index and high PSD value). When there is
uniform generalized depression (the loss of sensitivity at each point is identical), there is no
dissimilarity in the loss of sensitivity and hence, the contour of hill of vision is smooth and the height
of hill of vision is decreased (Low PSD and high mean deviation index).

CORRELATION BETWEEN PSD VALUE AND PATTERN DEVIATION PROBABILITY PLOT

The PSD values can be correlated with pattern deviation probability plot. Whenever, the PSD value is
high (the sign of irregular loss of sensitivity) the pattern deviation probability plot will be abnormal.
When the PSD value is non-significant or without P value (that is either field is normal or there is
uniform generalized loss of sensitivity), we see normal pattern deviation probability plot.

ROLE OF PSD IN THE FOLLOW-UP TESTS

Increase in MD index and change in PSD indicate that there is progression of the field defect and it
may be confined to a localized area or to a localized area in generalized depression (irregular
generalized loss). Increase in MD index and no change in PSD indicate that there is progression of
the field defect and it is uniform generalized type.

PSD is the index of irregular loss of retinal sensitivity which is better appreciated by the different
deviation values in the total deviation numerical plot. Remember that PSD will be low and without
any P value in uniform generalized field defect and PSD will be high in localized and irregular
generalized field defects. PSD is not an index developed to tell the severity of field defect. It is
developed to pick up dissimilar deviation values in total deviation numerical plot. For all practical
purposes it is an index developed to pick up early localized field defect to diagnose glaucoma at an
early stage even before we appreciate the change in the MD index due to glaucoma.
6.

Change in the Global Indices

In a simple form of serial field analysis global visual field indices can be looked into for deterioration
or improvement.

In progression of glaucoma the PSD and MD indices will increase due to increase in the extent or
depth of focal visual field defect. The MD index and total deviation probability would worsen in case
of development or progression of cataract. In change analysis printouts the Mean Deviation index
can be plotted as a function of change (linear regression).

The change in MD over time Is compared with database of stable glaucoma patients and illustrated
graphically to show whether significant visual field progression has occurred over time.

The PSD and CPSD indices increase initially as scotomas develop but may not change subsequently in
the course of the disease. In the advanced disease PSD and CPSD may decrease due to extensive
areas of visual field loss with equally poor sensitivity decreasing pointto-point variability.
9.

Global indices and analysis options

The statistical package for each automated perimeter Produces an in-depth statistical analysis of the
visual field test results. It Performs three important functions:

1. It can point out suspicious areas that otherwise might not be evident until subsequent testing.

2. It can identify areas that look suspicious but which, in fact, compare favourably with normal

data.

3. Using results from a series of tests, it can provide a highly sensitive and informative analysis of
changes in the patient’s visual field over time.

The Humphrey and Octopus perimeters contain Information of the decibel values expected at each
point of the normal age matched visual field over a wide age range.

Statpac Is the statistical programme used by the Humphrey Field analyzer to analyse the data from
single, or multiple, visual field assessments. EyeSuite Is the database used by the Octopus 900
Perimeter for its analysis.

Once A test has finished, the results of that test are then compared to the computers’ database of
agematched normals to determine whether the test result is also normal or whether a visual field
defect has been recorded. There are further software options that can be used for analysis of visual
field data. These include Peridata, PROGRESSOR, Medisoft and Open Perimetry Interface among
others (DeMoraes et al. 2012; Gardiner and Crabb 2002; Turpin et al. 2012; Viswanathan et al. 1997).

Both Humphrey and Octopus perimeters use similar global indices to provide information about the
visual field result (Figures 2.13 and 2.14). These include mean deviation (MD), pattern Standard
deviation (PSD), Standard loss variance (sLV), short-term fluctuation (SF), Corrected pattern standard
deviation (CPSD) And corrected standard loss variance. In addition, the Humphrey Field analyzer
provides a glaucoma hemifield test and box plot of results, whereas the Octopus 900 perimeter
provides a mean sensitivity (MS), Bebie curve, cluster analysis and polar analysis.

The MS is the overall average of all responses in decibels from the visual field test. The MD is the
overall departure of the average deviation (MS) of the visual field result from that expected of a
normal field of the same age group. In normal results this value is low and within ±2 dB: in abnormal
Visual field results, the value is high. If the MD is lower than found in 10% of the normal population
with reliable visual fields, a percentile is given at five significant levels (p < 10%, 5%, 2%, 1% and
0.5%).

In Humphrey perimetry, the MD is the weighted mean of all the numbers displayed in the total
deviation plot, which are the deviations from the average normal values for age (Funkhouser and
Fankhauser 1991). All tested locations are included except for the two which might include the
physiologic blind spot.

Each deviation from normal is weighted according to the variance of normal values at that location,
thus points with low variance (those that are closer to fixation) are more important than points with
higher variance. In Octopus perimetry, the calculation of the MD is not weighted as the
arrangement of stimulus locations is such that more locations are grouped closely together centrally
and further apart peripherally.
Thus, the Octopus Mean defect Is the Average of the total deviation values in the field test. The MD
Index signifies overall severity of visual field loss. It is affected both by the degree of loss and the
number of affected locations. The PSD is a global indexand is determined by the variation from the
normal hill of vision. The normal curve of a visual field has the highest decibel value at the central
foveal area with gradual reduction towards the periphery. There Should be no response at the blind
spot.

A normal Hill of vision will give a low PSD value. Where There is localized loss of vision such as with
paracentral scotomas or arcuate defects, the hill of vision will be deviated from the norm and a high
PSD Value will be obtained. As More visual field becomes involved with pathology with overall
reduction in sensitivity, the PSD Value will change to a lower value as the overall hill of vision
reduces across all affected areas of the visual field. When The entire field of vision becomes
involved, the hill of vision is then depressed as a whole. Thus the PSD will return to lower values as
visual field loss increases in severity. The Octopus sLV is the local heterogeneity of a defect. It is
small in fields with generalized damage and increases with the number and depth of localized
scotomas (Weijland et al. 2004).

The sLV is similar to the PSD. Visual Fields with the agenormal sensitivity at each point will have a
value of 0, As will visual fields in which every point is uniformly depressed from the age-normal
value. The Largest deviation will be registered for focal, deep visual field defects

Where the MD, PSD, sLV or CPSD values exceed those found in 10% of the normal population data, a
percentage is given at five significant levels (10%, 5%, 2%, 1% And .5%).