BASICS OF

PERIMETRY
 Visual field

Visual field - sum total

?
Binocular visual field is
of visual perception for
the combined visual
an eye fixed on a
perception of both eyes
stationary object of
under the same
regard with the head
restrictions on
and body held fixed in
movement.
position.
 Traquair- described an
island of vision in the sea
of darkness

The island represents the

perceived field of vision, and
the sea of darkness is the
surrounding areas that are not
seen.
VISUAL FIELD
• The field of vision is often depicted as a three
dimensional hill, with the peak sensitivity to stimuli
occurring at the point of fixation under photopic
conditions, decreasing rapidly in the 10º around
fixation, and then decreasing very gradually for
locations further in the periphery.
 SCOTOMA

• NEGATIVE SCOTOMA - Nerve fibers pass through the sclera at the optic nerve
head, typically 10-15º nasal to fixation. At this location, no photoreceptors are
present, creating a normal absolute scotoma.[3]
• POSITIVE SCOTOMA -perceived as black spot within the field of vision
H
I
L
L

O
F

V
I
S The hill is highest at fixation, where visual sensitivity is
greatest. The height of the hill of vision declines toward
I the periphery as visual sensitivity diminishes.
O
n
EXTENT OF FIELD

BINOCULAR FIELD
 measured using
Visual fields
PERIMETERS

Perimetry is the systematic measurement of differential

light sensitivity in the visual field by the detection of the
presence of test targets on a defined background
 PERIMETRY

KINETIC STATIC
Moving the test object from Stimulus remains fixed at a
a non seeing to a seeing certain location within the
area, and recording the point field, with the intensity
at which it is first seen in increased until it is seen by
relation to fixation. the subject.
Eg – Goldmann’s perimeter Eg – HFA, Octopus etc.
 KINETIC PERIMETRY
(test object moves from nonseeing
to seeing area)

STATIC PERIMETRY
(measures sensitivity of retina
at a given point)
KINETIC PERIMETRY

A line within the visual field which connects points of

equal sensitivity or threshold is defined as an isopter

STATIC PERIMETRY
HISTORICAL CONSIDERATIONS

Ptolemy in 150 BC attempted to document

visual fields

Tangent screen was developed by Jennik

Petersen Bjerrum in 1889

1945 – Goldmann perimeter

1970 – octopus perimeter

1982 – HFA was first displayed at AAO.

 PERIMETERS

AUTOMATED
MANUAL
Stimulus location is changed
Stimulus is moved by hand
by a computer, as in the
as in the Goldmann.
Humphrey visual field.
M
A
D Better examination of peripheral field.
N
E Reveal scotomas that were missed
U M between the testing point in static
A E perimetry.
L R Better in cases of central scotoma.
I Neuro-ophthalmology.
P T
S
E
R
I
M Less reliability and
reproducibility.
E Less sensitive in detecting early
T visual field defect.
E Lack of fixation monitoring.
R Lack of normative data.
S
 Automated static perimetry

Current gold standard to diagnose

glaucoma and for its management.

ADVANTAGES
DISADVANTAGES
 Reproducible testing conditions.
 Data storage capability.  Expensive
 More sensitive testing.  Time consuming
 Easy operation and menu driven
software - easy to learn and to use
 In this stimulus is stationary and its characters
are altered till it is visible.

Factors affecting the stimulus visibility are:

BRIGHTNESS
STIMULUS BACKGROUND OF
SIZE ILLUMUNATION STIMULUS

Kept constant Varied by the use

31.5 asb units of attenuation
Goldmann
filters
size III
 GOLDMANN TARGET
SIZES
Name Diameter (mm) Area (mm2)

V 9.03 64

IV 4.51 16

III 2.26 4

II 1.13 1

I 0.56 0.25

0 0.28 0.0625

Increasing the size of the target is

theoretically equivalent in effect to
increasing the brightness by 5 dB.
A small shift in the dB scale represents a major change in the
intensity of light in terms of asb units.
RELATIVE UNIT- DECIBELS (DB)
ABSOLUTE UNIT- APOSTILBS (ASB)
 Points to be noted when there is a decrease in retinal
sensitivity:

 The degree of decrease in retinal threshold.

 The location of decrease of retinal threshold.
 Is the degree of fall of retinal sensitivity statistically
abnormal.

3 dB decrease in
measured threshold
value always means
that the eye lost approx
half of the retinal
sensitivity.
 PERIMETRIC
UNIT
HARDWARE

CONTROL
COMPONENTS UNIT
OF
AUTOMATED
PERIMETER

SOFTWARE
hardware
 CO
IC NT
TR
E RO
I M L
E R UN
P IT
UN IT
 PERIMETRIC UNIT

STIMULUS
Size
BACKGROUND
Brightness
Illumination
Duration
Distance
The stimulus presented over a longer period of time may become
more visible, the phenomenon called temporal summation.

STIMULUS
DURATION – 0.2 sec

However, after the temporal summation is complete the

image is not seen any better.

STIMULUS DISTANCE
– 33 cm
FIXATION TARGET

SMALL DIAMOND
LARGE DIAMOND
CENTRAL located below the central
located below the centra
target and should be
Yellow light in the center target and is used for
used if the patient cannot
of the bowl patient with central
see the central fixation
scotoma
light
 CONTROL UNIT

• DIALOGUE SCREEN / KEY BOARD

• FIXATION CONTROL
 C.C.T.V
 HEIJL KRAKAU SYSTEM
 EYE MOTION SENSORS

• DATA STORAGE

- HARD DISC / FLOPPY DISC

- PRINTERS
 FIXATION
CONTROL

HEIJL KRAKAU EYE MOTION

CCTV
SYSTEM SENSORS
S
O
TESTING
F PATTERN

T
W TESTING
A STRATEGIES

R
E
 TESTING
PATTERN

THRESHO SCREENIN
LD TEST G TEST

CENTRAL PERIPHER SPECIALIT

TESTS AL TESTS Y TESTS

• Central 30-2 • Peripheral

• Central 24-2 60-4
• Central 10-2 • Neurological 20
• Nasal step
• Macular & 30
• Temporal
programme crescent
THRESHOLD

The visual threshold is often thought of minimum brightness which the

patient can see at a given location in the same field but IT IS NOT
SO……
IF A PARTICULAR INTENSITY OF LIGHT I
SHOWN 100TIMES & …
• it is appreciated 50times
THRESHOLD • Stimulus intensity which as 50%
seeing

SUPRATHRESH • Stimulus intensity is seen 90%

OLD
INFRATHRESH • Stimulus intensity is seen 15% of
OLD
Main aim of static perimetry is to find out the
threshold of the retina at various points.

Physiological capacity to detect a stimulus at a given location

under specified conditions
OR
Threshold of a given point is defined as that stimulus
intensity which has 50% probability of being seen.
 TESTING
STRATEGI
ES

FULL SITA
THRESHOL FAST PAC STANDAR SITA FAST
D D
Determination of threshold by using
Staircase/ bracketing method – for full
threshold strategy
• Strategy: The options are
1. Full threshold: Full threshold is rarely indicated, since newer
thresholding algorithms are equally as valid and much faster.
2. Fastpac
3. SITA-standard
4. SITA- fast
• However with the newer Swedish Interactive Thresholding Algorithm
(SITA), testing is even more rapid, yet validity is protected and possibly
enhanced. SITA standard is twice as fast as full threshold and SITA-fast is
twice as fast as SITA Standard.
 B
POINT
DENSITY

C
A Testing
NO. OF patterns DEGREE
TEST OF BARE
POINTS VARIABLE AREA
S

EXTENSI
ON OF
FIELD
TESTING D
 30-2 CENTRAL
THRESHOLD TEST
PATTERN
A. 76
B. 6°
C. 3°

24-2 CENTRAL
THRESHOLD TEST
PATTERN
A. 54
B. 6°
C. 3°
 10-2 CENTRAL
THRESHOLD TEST
PATTERN

A. 68
B. 2°
C. 1°
5° area of 10-2
central pattern

MACULAR
PROGRAMMING TEST
PATTERN
A. 16
B. 2°
C. 1°
 SUMMARY
30-2 24-2 10-2 MACULAR
PROGRAMM
E

TEST POINTS 76 54 68 16

POINT 6 6 2 2
DENSITY (°)

FIELD (°) 30 24 10 5

BARE AREA 3 3 1 1
(°)
 24-1 CENTRAL 24-2 CENTRAL
THRESHOLD PATTERN THRESHOLD PATTERN

Test points fall on vertical and horizontal

axis
SELECTION OF TESTS IN PATIENTS OF GLAUCOMA
ACCORDING TO THE STAGE OF GLAUCOMA
TESTING PATTERN + TESTING
STRATEGY
20 mins

14 mins

10 mins

7 mins

5 mins
EVALUATION OF HFA PRINTOUT

1. Patient data and test parameters

2. Reliability indices
3. Gray scale
4. total deviation plot
5. pattern deviation plot
6. Global indices ( MD, PSD, SF, CPSD)
7. Glaucoma hemi field test (GHT)
8. Actual threshold value
5. PATTERN DEVIATION PLOT

• Same as total deviation plot except here stat pack software has corrected the
results for the changes caused by cataract, small pupil, etc.
 6.GLOBAL INDICES
PATTERN STANDARD
DEVIATION
MEAN DEVIATION
Mean difference between • Measure of variability
normative data for that age within the field
compared with collected
• Actually points out
data in db
towards localized field
Indicator for general loss
depression of field
• Identifying early defects
Worse than normal is
indicated with negative
value
7.GHT
• GHT compares 24-2 visual fields into 10
regions, with 5 inferior regions representing
mirror images of 5 corresponding superior
regions. Differences between corresponding
superior and inferior zones are compared with
the differences present in the population of
normal controls
GLAUCOMA HEMIFIELD TEST

• 5 CLUSTERS
• Not designed to
detect a temporal
defect
GHT CAN BE

GHT-Abn
GHT- ONL GHT-Borderline
sensi
Values between any sector in Values between any sector in
If the best pa
U & L zone differ to an extent U & L zone differ to an extent
depressed to a
found in 1% of the population found in 3% of the population
in <0.5% of t

GHT- Abnormal high

sensitivity
GHT- WNL
Overall sensitivity in the best
None of the above conditions
part of the VF to be higher
seen
than found in 99.5% of the
population
I • 30-2 FULL THRESHOLD
N GLAUCOMA
SUSPECT
• 30-2 SITA STANDARD

D
I ESTABLISHED
GLAUCOMA
• 24-2 FULL THRESHOLD
• 24-2 SITA STANDARD
C AND FOLLOW • 24-2 FAST PAC
UP
A
• 10-2 FULL THRESHOLD
T ADVANCED • 10-2 SITA STANDARD
GLAUCOMA
I • MACULAR
PROGRAMME
THOSE WHO
O CANNOT
N WITHSTAND
LONG
• 24-2 SITA FAST

S DURATION
FEW TERMINOLOGIES

• Scotoma: Area of reduced sensitivity surrounded by a more sensitive area

• Depression: Area of reduced sensitivity without a normal surround
• Isopter: A threshold line joining points of equal sensitivity on a visual field
chart
• Fixation: Part of visual field corresponding to fovea centralis
• Central field: Portion of visual field within 30° of fixation
• Bjerrum’s area: Central visual field within 25° of fixation
WHAT IS SCOTOMA??
FIELD IN A PT DEVELOPING CATARACT
VISUAL FIELD LOSS

1. Glaucomatous visual field loss

2. Neurological visual field loss
3. In retinal disease
GLAUCOMATOUS VISUAL FIELD LO
 PROGRESSION OF VISUAL FIELD DEFEC
GLAUCOMA

A. Early non specific changes

1. Isopter contraction
2. barring of blind spot

B. Early significant changes

1. Small wing shaped para central scotoma
2. Siedal’s or sickle shaped scotoma
3. Nasal step scotoma
CONT…

C. Late significant changes

1. Arcuate / bjerrum’s scotoma
2. Ring / double arcuate scotoma

D. Advanced defect
3. Tubular vision
4. No light perception
MNEMONIC

• Isopter contraction
• Baring of blind spot
IC (see)
• Wing shaped paracentral scotoma-
BB occurs in jerrums area within central
10degree
wings &
• Siedel scotoma- comma shaped
SAD extension of blind spot
steps • Arcuate or bjerrums scotoma
• Double arcuate scotoma
 Isopter contraction
IC (see) Baring of blind spot
Wing shaped paracentral scotoma-
BB occurs in jerrums area within central
wings & 10degree
Siedel scotoma- comma shaped
SAD extension of blind spot
Arcuate or bjerrums scotoma
steps Double arcuate scotoma
Roenne’s central & peripheral
NERVE FIBRE LAYER
NERVE FIBRE LAYER
GLAUCOMATOUS VISUAL FIELD LOSS
SUPERIOR ARCUATE SCOTOMA
DOUBLE ARCUATE SCOTOMA
SUPERIOR NASAL STEP
WHAT IT MAY
BE??

COMBINATION OF CATARACT AND

GLAUCOMATOUS FIELD DEFECT
NEUROLOGICAL VISUAL FIELD LOSS
SUPERIOR ALTITUDINAL DEFECT
ALTITUDINAL FIELD LOSS
HETERONYMOUS HEMIANOPIA
HOMONYMOUS HEMIANOPIA
HOMONYMOUS LEFT INFERIOR QUADRANTANOPIA
SUPERO TEMPORAL QUADRANT ANOPIA IN RIGHT EYE
COMMON PATTERNS OF ARTIFACTU
TEST RESULTS
EYELID
ARTIFACT
CLOVERLEAF DEFECT
THANKYOU…….