visual field quiz

Visual Field Quiz

All that glitters isn’t glaucoma

TBH 11th Sept 2015

Static vs Kinetic

Static vs Kinetic

What type of visual field defect might you expect to see in this patient?

Superior nasal step or superior arcuate scotoma due to the

prominent notch in the optic nerve

What is a likely diagnosis?

This is a Humphrey’s visual field from a man who comes in for a neurophthalmic eye examination

1. Describe the visual field defect2. What is the likely cause of such

a visual field defect?3. What else can cause this visual

defect?4. What type of nystagmus can be

associated with this field defect?

This is a Humphrey’s visual field from a man who comes in for a neuropthalmic eye examination

1. Describe the visual field defect• Incongruous bitemporal visual field

defect that respects the mid-line2. What is the likely cause of such a

visual field defect?3. What else can cause this visual

defect?4. What type of nystagmus can be

associated with this field defect?

This is a Humphrey’s visual field from a man who comes in for a neuropthalmic eye examination

1. Describe the visual field defect• Incongruous bitemporal visual field defect

that respects the mid-line2. What is the likely cause of such a visual

field defect?• A sellar chiasmal mass eg pituitary

adenoma3. What else can cause this visual defect?4. What type of nystagmus can be

associated with this field defect?

This is a Humphrey’s visual field from a man who comes in for a neuropthalmic eye examination

1. Describe the visual field defect• Incongruous bitemporal visual field defect that

respects the mid-line2. What is the likely cause of such a visual field

defect?• A sellar chiasmal mass eg pituitary adenoma

3. What else can cause this visual defect?• Pseudo bitemporal field defects include: tilted

optic discs, sectoral RP, optic nerve head drusen…4. What type of nystagmus can be associated

with this field defect?

This is a Humphrey’s visual field from a man who comes in for a neuropthalmic eye examination

1. Describe the visual field defect• Incongruous bitemporal visual field defect that respects

the mid-line2. What is the likely cause of such a visual field defect?

• A sellar chiasmal mass eg pituitary adenoma3. What else can cause this visual defect?

• Pseudo bitemporal field defects include: tilted optic discs, sectoral RP, optic nerve head drusen…

4. What type of nystagmus can be associated with this field defect?• See-saw nystagmus which is conjugate clockwise then

counterclockwise rotation of the eyes from 150-300 cycles per minute. There is elevation of the intorting eye and depression of the extorting eye which appears as if the eyes are see-sawing up and down

Patient wears thick spectacles High + or High -

Describe 9 sections of the

visual field printout

1. 2. 3. 4. 5. 6. 7. 8. 9.

1

5

432

6 8

7

99

Describe 9 sections of the

visual field printout

1. Test Selection and General Information

2.

5

432

6 8

7

99

Describe 9 sections of the

visual field printout

1. Test Selection and General Information

2. Reliability Indices3.

5

43

6 8

7

99

Describe 9 sections of the

visual field printout

1. Test Selection and General Information

2. Reliability Indices3. Numeric Results4.

5

4

6 8

7

99

Describe 9 sections of the

visual field printout

1. Test Selection and General Information

2. Reliability Indices3. Numeric Results4. Greyscale

Results

5 6 8

7

99

Describe 9 sections of the

visual field printout

1. Test Selection and General Information

2. Reliability Indices3. Numeric Results4. Greyscale

Results5. Total Deviation

6 8

7

99

Describe 9 sections of the

visual field printout

1. Test Selection and General Information

2. Reliability Indices3. Numeric Results4. Greyscale

Results5. Total Deviation6. Pattern Deviation

8

7

99

Describe 9 sections of the

visual field printout1. Test Selection

and General Information

2. Reliability Indices3. Numeric Results4. Greyscale

Results5. Total Deviation6. Pattern Deviation7. Glaucoma

Hemifield Test

8

99

Describe 9 sections of the

visual field printout1. Test Selection

and General Information

2. Reliability Indices3. Numeric Results4. Greyscale

Results5. Total Deviation6. Pattern Deviation7. Glaucoma

Hemifield Test8. Global Indices9

9

Describe 9 sections of the

visual field printout1. Test Selection

and General Information

2. Reliability Indices3. Numeric Results4. Greyscale

Results5. Total Deviation6. Pattern Deviation7. Glaucoma

Hemifield Test8. Global Indices9. Probability

Symbols and Gaze Graph

Where is the likely pathology?

Where is the likely pathology?

• Cataract

Describe the visual field and most likely diagnosis

Describe the visual field and most likely diagnosis

• POAG – nasal step

Describe the visual field and most likely diagnosis

Describe the visual field and most likely diagnosis

• POAG

What happened here?

What happened here?- lens holder artifact. Sharp fall off with absent nasal

step = artifactual

Both patients scored 3/14 fixation losses. What is the difference

between the two patients?

Describe the field. Any explanation?

Describe the field. Any explanation?

• Clover leaf = patient fatigue

This is not glaucoma. What is another likely diagnosis?

This is not glaucoma. What is another likely diagnosis?

• Age related macular degeneration

This is not glaucoma. What is another likely diagnosis?

This is not glaucoma. What is another likely diagnosis?

• Retinitis Pigmentosa

An 85 year old woman with mild ocular hypertension, but a healthy optic nerve was

diagnosed with glaucoma based on the appearance of the VF. Without seeing the

patient what do you suspect?

An 85 year old woman with mild ocular hypertension, but a healthy optic nerve was

diagnosed with glaucoma based on the appearance of the VF. Without seeing the

patient what do you suspect?

• Involutional Ptosis

60 year old woman says that she needs a pressure check. She has been treated for glaucoma for 3 years with a prostoglandin analog in both eyes. VA 6/6 OU, IOP 14 OU, VF = superior arcuate defect in the left eye. Right optic nerve is normal, left optic nerve

shown below1. What does her optic

nerve photo show?2. What is the

pathophysiology3. What tests can confirm?4. What is your

management?

60 year old woman: 1. Optic nerve head

drusen2. Calcified hylaline

bodies in prelaminar optic nerve

3. B-scan, CT, AF4. ?Glaucoma or

drusen?1. VF stable?2. IOP over time?3. Any changes in ON

appearance?4. If no baseline?

60 year old woman: 1. Optic nerve head

drusen2. Calcified hylaline

bodies in prelaminar optic nerve

3. B-scan, CT, AF4. ?Glaucoma or drusen?

1. VF stable?2. IOP over time?3. Any changes in ON

appearance?4. If no baseline?

• VF, Gonio, CCT, ON images

60 year old woman: 1. Optic nerve head

drusen2. Calcified hylaline

bodies in prelaminar optic nerve

3. B-scan, CT, AF4. ?Glaucoma or drusen?

1. VF stable?2. IOP over time?3. Any changes in ON

appearance?4. If no baseline?

• VF, Gonio, CCT, ON images

63 year old man reports difficulty in reading. He says that the words are clear, but he has trouble following the lines of text and loses his place. He denies any change in vision, headaches, or other neurologic symptoms. Exam shows visual acuity of 6/6 in both eyes at distance and near, normal pupillary response without a RAPD, very early cataract and normal fundus exam.

Q: What other tests would you perform?

63 year old man reports difficulty in reading. He says that the words are clear, but he has trouble following the lines of text and loses his place. He denies any change in vision, headaches, or other neurologic symptoms. Exam shows visual acuity of 6/6 in both eyes at distance and near, normal pupillary response without a RAPD, very early cataract and normal fundus exam.Q: What other tests would you perform? EOM, Amsler and VF

Additional information: Extraocular motility is full and the eyes are orthsphoric. Amsler grid reveals a blurry area inferotemporal to fixation in the right eye…

Humphrey VF testing on next slide…

Q: What does the VF test show?

Q: Where is the pathology?

Q: What would you do next?

Q: What does the VF test show?Right homonymous inferior quadrantic

scotomas

Q: Where is the pathology?Left Parietal Lobe

Q: What would you do next?Neuroimaging

You find a VF lying on a table in the clinic with no name… You try to find the patient…

Q: How might the patient present?Q: What signs would you find?

This patient has been treated for glaucoma for 2 years due to findings on her VF. The VF series is sent to you for opinion.

What is happening? What would your management be?