CONFRONTATION VISUAL FIELDS

ALLIED OPHTHALMIC TRAINING

KATHRYN DURNFORD, MS3

MEDICAL STUDENT | UNIVERSITY OF UTAH

SOPHIA FANG, MD
FELLOW | MORAN EYE CENTER

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TEST YOUR KNOWLEDGE!

Which of the following conditions can lead to

visual field defects?
a. Retinitis pigmentosa
b. Glaucoma
c. Macular degeneration
d. All of the above

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TEST YOUR KNOWLEDGE!

Which of the following conditions can lead to

visual field defects?
a. Retinitis pigmentosa
b. Glaucoma
c. Macular degeneration
d. All of the above

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TEST YOUR KNOWLEDGE!

When testing a patient’s visual field, you

have the patient keep both eyes open.

True or False?

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TEST YOUR KNOWLEDGE!

When testing a patient’s visual field, you

have the patient keep both eyes open.

True or False

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WHAT IS A PERSON’S VISUAL FIELD?

• A visual field defines the space that a person can see while keeping their head
in the same position
• The visual field radiates out from the pupil and extends in a cone-like shape – this
is important to understand when thinking about how you test the perimeter, or
edges, of the visual field
– Objects that are further away from the person are more likely to be within that person’s visual field
– You can test this by seeing how quickly you lose sight of your fingers if you hold them close to your face
versus extending your arms while looking straight ahead

Diagram showing the cone- Diagram showing the

like shape of the visual field – limitations of each eye’s visual
notice how quickly it expands field. The visual field extends
as the distance increases . furthest in the temporal side as
it is not blocked by the nose.
Binocular vision occurs where
the two intersect (shown in
purple).

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WHAT IS A PERSON’S VISUAL FIELD?
• Scotoma refers to an area of a person’s visual field that light perception is
entirely absent or the light perception is diminished; sometimes referred to as a
visual field defect
• The size, shape, and the quality of vision lost are all characteristics of a scotoma
• The type of scotoma provides information to the ophthalmologist about the
cause of the defect
• Below are a few examples:

Central Scotoma Arcuate scotoma

https://commons.wikimedia.org/wiki/File:Visual_field_centrocaecal_scotoma.png#filelinks
https://commons.wikimedia.org/wiki/File:Visual_field_arcuate_scotoma.png
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WHAT IS A PERSON’S VISUAL FIELD?

• For each eye there is a blind spot in the vision

– This is where the ganglion cells of the retina merge to form the optic nerve of the eye and so there are
no photoreceptors (rods and cones) in that one area of the retina
– Fun fact: the optic nerve is the only nerve in the body that can be visualized clinically and non-invasively
– There are websites where you can practice finding your own blind spot
(https://www.aao.org/museum-eye-openers/experiment-blind-spot)

Blind Blind
spot spot
OS OD

Patient’s Perspective Optic nerve head

https://commons.wikimedia.org/wiki/File:NERVIOPTIC_OD.jpg

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PERFORM A CONFRONTATION VISUAL FIELD
(CVF) – STEP 1: ALIGN PATIENT
• Have the patient seated 2-3 ft away from
2-3 ft or 0.5-1 m
you - if you both are seated your knees
would be almost touching
• Align the height of your eyes with the patient
- avoid standing over the patient
• Facing the patient, cover or close your left
eye
• Ask the patient to cover their right eye
completely (can use an occluder) – No
peeking!
• Instruct the patient to stare at your right eye
and to not follow your fingers

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PERFORM A CONFRONTATION VISUAL FIELD
(CVF) – STEP 2: TEST VISUAL FIELD
• Next hold 1, 2, or 5 fingers in one of the four
quadrants (avoid holding 3 or 4 fingers) and ask
the patient to count them – show fingers exactly
halfway between you and the patient
• If the patient can’t see the fingers in the
periphery, you can move the fingers in a few
OS OD
inches towards the center and see if they can
see them – this counts as a defect! Patient’s Perspective:
4 Quadrants that need to be
• Once you have successfully tested the 4 tested one eye at a time – she is
testing
quadrants of one eye, switch and test the other
eye
• If the patient was able to count your fingers in all
4 quadrants, then you can document the VF as
“CVF full”
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HOW TO DOCUMENT THE CVF

• You document the patient’s visual field as if you are looking from their
perspective
• Example: If the patient couldn’t count the fingers in their left upper quadrant of
the right eye, you would document it like the picture below

OS OD

• It may be helpful to imagine standing behind the patient as if you could look
through and see what they are seeing

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TROUBLESHOOTING AND TIPS

• If the patient looks away from you eye: first redirect their gaze back to your eye,
and then retest the quadrant that you were testing when the patient looked
away
• Avoid wiggling fingers, as this is testing a different sensory input for the brain
• Slowly move fingers from where you, as the examiner, can’t read them until the
point that you can read them – the patient should now be able to read them as
well
• Remember you must match their eye level and the angle of their vision to
adequately test the visual field
• Be patient. It is not uncommon to have to redirect a patient’s fixation back to
your eye a few times and it may take them a few seconds to count your fingers

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ARE THERE OTHER WAYS TO TEST THE VISUAL
FIELD?
• Yes! There are automated machines that ophthalmologists can use
to obtain a more precise diagram of where the scotoma is located
and the shape of the defect.
• While an automated visual field machine can provide additional
information, a technician who is skilled in performing a confrontation
visual field can provide incredibly useful information about the health
of a patient’s eye.
• With experience performing the CVF correctly, you’ll learn to pick up
more subtle defects like central defects and nasal steps.

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EXAMPLE OF VISUAL FIELD TESTING
The patient’s right upper quadrant of the left eye (OS)
is being tested.

Notice that the patient’s gaze is focused straight

ahead and is not looking towards the fingers.

The examiner is covering her left eye with her right

hand so that she can use her left hand to assess the
patient’s right VF.

*For future reference, patients should have their hats removed or turned
around so that the brim is not obstructing the visual field
OS OD

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EXAMPLE OF VISUAL FIELD TESTING
The patient’s right lower quadrant of the left eye (OS)
is being tested.

Remember to present your fingers halfway between

you and the patient!

*For future reference, patients should have their hats removed or turned
around so that the brim is not obstructing the visual field
OS OD

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EXAMPLE OF VISUAL FIELD TESTING
The patient’s left upper quadrant of the left eye (OS)
is being tested.

The angle of the camera makes it appear as though

the examiner’s head is tilted – but remember that you
need to maintain the same level and angle of gaze
as the patient.

Notice how a patient’s visual fields can be assessed

anywhere. There is no special equipment needed!

*For future reference, patients should have their hats removed or turned
around so that the brim is not obstructing the visual field
OS OD

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EXAMPLE OF VISUAL FIELD TESTING
The patient’s left lower quadrant of the left eye (OS) is
being tested.

Remember to first test the outer limits of the visual

field.

It is often helpful to recognize whether the defect

was nasal or temporal when documenting. As you
can see from the images, it can be tricky to translate
what the patient is seeing from your perspective.

Once done, repeat the steps with the other eye!

*For future reference, patients should have their hats removed or turned
around so that the brim is not obstructing the visual field
OS OD

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