VISUAL FIELD TESTING

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°

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.

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
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
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
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.

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
Banded in 5db groupings

3. Probability Plots
Total and pattern deviation plots

4. Global Indices
Mean sensitivity, Mean deviation, Pattern standard deviation
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

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
 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