Seminar on Assessment of Visual field.

Automated Perimetry.

Dr. Ricky Mittal.

What is the normal visual

field?
Traquair-island of vision
surrounded by the sea of
darkness.
3 dimensional- strategies that
are the foundation of all
perimetric examinations.
X-Y axis, Z axis.
Kinetic perimetry:
extent along X-Y axis.
Static perimetry: differential
light sensitivity ,altitude of
the hill of vision along
vertical z axis.

Extent of visual field, XY axis:

Basic terminologies:

Threshold :
Physiological capacity to detect a stimulus at a given
location, that stimulus intensity that has a 50%probability of
being seen.
Apostilbs:
Absolute units of light intensity.
Luminance of test target.
1 asb=.3183 candela/m2
Decibels:
Relative scale, created by manufacturers.
Attenuation of light by neutral density filters.
1dB=1/10 log units of attenuation of max. stimulus.
Measures sensitivity at each point.0to40dB.

Sensitivity Vs threshold:

Inverse relationship.

In automated perimetry, threshold is recorded in the inverted

decibel scale, and dimmer targets have higher decibel
values.

Therefore, threshold in decibels is directly proprotional to

retinal sensitivity.

Apostilbs Vs decibels:

Lumininance of test targets is measured in an absolute unit,

apostilbs.

Decibel is a relative scale created by manufacturers of

automated perimeters to measure sensitivity.

Inverted logarithmic scale with 0dB=brightest stimulus. Not

standardized.

Total deviation :difference between patients threshold measured

and value expected in age matched normals.

Global indices:

Mean deviation: mean difference between

sensitivities of age matched normals and subject.
Highlights overall depression, dB, STATPAC, p
value.
Indicated as:
-ve in Humphrey.
+ve in Octopus.
Pattern standard deviation: this is a measure of
degree to which the shape of patients field differ
from normal, extent of focal loss as a single value.
PSD can be normal when there is a diffuse loss.

primarily reflects retinal condition.

excludes conditions affecting the overall field.
PSD:
small value-normal field or diffuse loss.
scotoma -clearly abnormal.
advanced -PSD starts decreasing if many threshold values near
0dB.

SF: Intratest test variability, threshold at 10 predetermined points,

twice.
SD SF
indicator of patients consistency, pathology.
1-2.5dB.

CPSD: extent of focal loss in the visual field, taking short term
fluctuations in account i.e. which is not caused by SF.

Probability analyses:
symbolic represenation.
Statistical probability of a threshold value measured at a point that
exists in age-matched normals.
Darker the symbol lower the probability.
Comparison on a point by point basis.
Cataract, ref.error excluded.
Retinal condition.

Glaucoma hemifield test:

Compares five zones (along

the nerve fibre bundles) in
the upper field with their
mirror images in the lower
field.
A very good determinant of
the presence of glaucomatous
damage on a single field.
Does not analyze temporal
nerve fibre bundle defects.

Inference:
Outside normal limits.
<1%,0.5%.
Borderline.
3%
Abnormally low sensitivity.
5%
Abnormal high sensitivity.

higher than 99.5%

Within normal limits.

Basics of the Humphrey field

analyser:
Projection type automated static
perimeter.
Most popular, consistency of basic
hardware,
constant upgradation of the software on
the basis of clinical feedback from the
ophthalmologists.
The machine:
Viewing distance-33cms.
Background illumination-31.5asb.
Static mode, newer models - kinetic.

Stimulus size:
Goldman stimulus
size(1to5)
Stimulus duration:0.2
second.
Fixation monitor:
Heijl Krakau blind
spot technique, gaze
monitoring.

Data storage.
STATPAC: computerised statistical package
Comparison of patients results with age matched normal
data.
Patients own baseline with follow up data.
Newer HFA series: database of stable glaucoma patients for
glaucoma change probability analysis.

Interpretation of visual field:

Recognise artifacts:

Reliability.

Assessment of damage.

Baseline visual field exam:

2 fields min. baseline.
1st field-Central 30-2 threshold
2nd
-central 30-2 threshold within 1 to 2 months.
Provided:
Consistent ,no learning effect.
<2dB (MD).
If 1st field constricted or depressed:
Obtain 10-2 threshold test.
Retest with size5 stimulus(64mm2).
Or combine.

Artifacts

Lid.
Lens rim-too far or the eye is not centered.
Refractive error.
Learning effect.
Pupillary size.
Rapid fatigue.

Reliability:

False positives-tendency of the patient to press the

trigger not in response to seeing a stimulus but at
random, either as a response to an audible cue or
due to the expectation of the stimulus.
Ratio of such responses to the number of FP catch
trials done.
>33%FP rate is flagged with a double XX.
Low reliability.

False negative:

False negative responses are failure of the patient to

respond to stimulus 9 dB more intense than the previously
determined threshold at that point due to patient inattention
or fatigue.
Reason may be a tired patient.
A high FN rate may or may not be reliable.
Cloverleaf defect due to high FN.

Fixation losses:

Not all fixation losses represent true loss of fixation.

High fixation loss may indicate, centre of blind spot was
slightly mislocated.
If FP, FN rates and STF are low, then the high FL can be
discounted.
If two baseline fields are similar it can again be discounted.
Mislocation of the blind spot.
Macular disease.

Short term fluctuations:

Testing option, shows variability of patients response over a

single test period.
low (2dB) SF- good reproducibilty
high ( 3dB) SF-poor reproducibility

Minimum Criteria for Diagnosing

Acquired Glaucoma:

A Glaucoma Hemifield Test outside normal limits on at least

two fields.
or

A cluster of three or more non edge points in a location

typical for glaucoma, all of which are depressed on the PD
plot at p<5% level and one of which is depressed at p
<1%level on two consecutive fields.
or

A CPSD that occurs in less than <5% of normal fields on two

consecutive fields.

Early defect:
Neither extensive nor near fixation.
Mean deviation index (MD) better than -6dB.
On PD plot:
1.<25%(18) points are below 5% level.
2.< 10 points below 1% level.
Central 5-no points having less than 15dB sensitivity.

Moderate defect:
MD<-12dB.
1.PD-<50%( 37) points < 5% and < 20 points <1%.
Central 5-no points with 0dB.
Only one hemifield may have a point in central 5 with
<15dB sensitivity.

Severe defect:
Any of the following:
1.MD plot >-12dB
2.PDplot:
>37 points depressed below<5%.
>20 points depressed below 1%.
Any point in central 5has sensitivity of 0dB.
Central 5-points <15dB in both hemispheres.

Recognition of progressive damage:

1.new defect.
2.deepening of pre exisiting defect.
3.expansion of pre existing defect.
4.entire field develops decreased sensitivity.

How would u approach?

Compare baseline field to each individual field

Study the entire series.

Compare with baseline field:

1.For a new defect in previously normal area.
Cluster of 3 or or more non edge points each
of which declines by 5 or >5dB.
2.For deepening of pre existing defect.
A cluster of 3 or more non edge points, each of which declines
by 10 or>10dB.
3.Generalized depression:
Decline of all points by 3dB.

Glaucoma change probability programme:

Point by point probability of any change in baseline field

and new field.
1.new defect: 3 or more non-edge points each of which,
p<5%,on two consecutive fields.
2.deepening of pre existing defect: part of a scotoma,
cluster, p<5%.
3.expansion
:
3.
Within 15 of field-2 previous normal points.
Outside 15 of field-3 previously normal points depressed
with p,5%.

Generalized depression:
Decline in MD, p<1%.

References:

Illustrated Automated Static Perimetry G.R.Reddy.

Testing of the Field of Vision-Douglas R.Anderson.
Clinical Decisions in Glaucoma-Elizabeth Hodapp,Richard
K.Parrish,Doughlas R.Anderson.
Visual Field Examination-A.K.Gupta ,Reena
M.Chaudhary,Charu Tandon.

.Thank you.