visual field testing and interpretation
TRANSCRIPT
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VISUAL FIELD TESTING
AND INTERPRETATION
HIRA NATH DAHAL
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PRESENTATION LAYOUT• INTRODUCTION ON VISUAL FIELD
• NORMAL LIMITS OF VISUAL FIELD
• SHORT OVERVIEW ON HISTORY OF VF
• TERMINOLOGIES RELATED TO VF
• VISUAL FIELD TESTING METHODS
• KINETIC, STATIC
• INTERPRETATION OF VF REPORTS
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INTRODUCTION
VISUAL FIELD
• THE VISUAL AREA THAT IS PERCEIVED SIMULTANEOUSLY BY A FIXATING EYE.
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RETINA VS VISUAL FIELD
Optic disc
Nasal to the fovea – Seen in temporal VF as a Blind spot
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TRAQUAIRS FIELD OF VISION
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HILL OF VISION
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Normal limits of visual field
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SHORT HISTORY OF VISUAL FIELD• IN B.C 150, PTOLEMY: USED SOME FORM OF PERIMETRIC
DEVICE TO MEASURE EXTEND OF VF
• FIRST CLINICAL INVESTIGATION OF VF DEFECT – HIPPOCRATES IN 5TH CENTURY, HEMIANOPIC FIELD DEFECT
• FINALLY IN 1604 KEPLER EXPLAINED THE PRINCIPLE OF SIGHT IN TERM OF AN INVERTED RETINAL IMAGE –
– AN STAGE FOR MODERN INVESTIGATION OF VF
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HISTORY….• IN 1666, MARIOTTE DISCOVERED
PHYSIOLOGICAL BLIND SPOT
• IN 1801, YOUNG STATED THE NORMAL
EXTEND OF VF OF AN EYE
• VON GRAEFE MAPPED OUT BLIND SPOT,
CENTRAL SCOTOMAS, CONSTRUCTION OF
ISOPTER.
• INTRODUCED VF IN CLINICAL MEDICINE
FOR THE FIRST TIME
• UNTIL 1869, FOERESTER INVENTED ARC
PERIMETER, TILL THEN VF PLOTTED ON
FLAT SURFACE
Thomas Young
Von Graefe
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HISTORY……• IN 1880, BJERRUM DEVELOPED
TANGENT SCREEN
• IN 1940, MARC AMSLER
INTRODUCED AMSLER GRID
• IN 1939 SLOAN DESCRIBED
STATIC PERIMETRY
• IN 1945 GOLDMAN
PERIMETER
• IN 1960 TUBINGER- MANUAL
TESTING OF BOTH STATIC AND
KINETIC PERIMETER
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FEW TERMINOLOGIES• THRESHOLD: THE WEAKEST TEST STIMULUS THAT IS JUST
VISIBLE IN A PARTICULAR LOCATION UNDER THE SPECIFIC
TESTING CONDITION.
• VARIES ACROSS THE VISUAL FIELD.
• SENSITIVITY: MOST SUBTLE CHARACTERISTICS OF A STIMULUS
THAT IS VISIBLE AT A SPECIFIC POINT IN SPACE.
• FIXATION: THAT PART OF VISUAL FIELD CORRESPONDING TO
FOVEA CENTRALIS.
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TERMINOLOGIES…• ISOPTER:
• LINE CONNECTING ALL POINTS IN THE VISUAL FIELD WITH THE
SAME THRESHOLD ( FOR A GIVEN TEST SPOT)
• BOUNDARY BETWEEN AREA OF VISIBILITY TO THE AREA OF NON-
VISIBILITY FOR A PARTICULAR STIMULUS
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TERMINOLOGIES…• SCOTOMA: LOCALIZED DEFECTS\DEPRESSIONS SURROUNDED BY
NORMAL VISUAL FIELD.
• ABSOLUTE: DEFECT THAT PERSISTS WHEN THE MAXIMUM
STIMULUS IS USED E. G BLIND SPOT.
• RELATIVE : DEFECT THAT IS PRESENT TO WEAKER STIMULUS BUT
DISAPPEARS WITH BRIGHTER STIMULUS.
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LOCATION OF VISUAL FIELD DEFECTS• CENTRAL
• 5 DEGREES OR LESS FROM THE POINT OF FIXATION
• PARACENTRAL
• >5 DEGRESS – 30 DEGREES
• CEACAL, PARACEACAL, PERICEACAL
• CENTROCECAL
• PERIPHERAL
• >30 DEGREES
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DESCRIPTIVE COMPONENTS OF VF DEFECTS•MONOCULAR DESCRIPTIONS–DENSITY• ABSOLUTE (NO VISUAL SENSATION) OR RELATIVE (DEPRESSED
VISUAL SENSATION)
–AREA• GENERAL OR LOCAL
–SHAPE• SECTORIAL (HEMIANOPIC) OR NON-SECTORIAL (REGULAR OR IRREGULAR)
–EXTENT• TOTAL OR PARTIAL
–POSITION• RT. OR LT. . TEMPORAL, NASAL, SUPERIOR, INFERIOR
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DESCRIPTIVE COMPONENTS OF VF DEFECTS
•Binocular description• Laterality•Unilateral or bilateral (homonymous/heteronymous)
•Equalness•Congruous or incongruous
•Additional description
•Awareness•Positive (defect perceived) or negative (defect not perceived)
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SIGNIFICANCE OF VISUAL FIELD TESTING
• FIND OUT THE EXTENT OF VF
• TO DIAGNOSE AND DETECT DISEASES AS WELL AS EXTENT OF
DAMAGE CAUSED IN VF BY THE DISEASE
• TO LOCATE POSSIBLE LESION IN NEUROLOGICAL DISORDER
• TO FIND OUT THE PROGRESSION OF DISEASES
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VISUAL FIELD TESTING METHODS/TOOLS
• CENTRAL
• AMSLER GRID: 200
• TANGENT (BJERRUM SCREEN): 300
• GOLDMANN
• AUTOMATED (OCTOPUS / HUMPHERY) :300
• PERIPHERAL
• CONFRONTATION
• GOLDMANN
• AUTOMATED 900 PROGRAMME
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PERIMETRY
• SYSTEMATIC MEASUREMENT OF VF BY THE USE OF A
PERIMETER
• MODERN PERIMETER • CONSIST OF A BOWL POSITIONED AT A FIXED DISTANCE FROM
THE EYE,
• ENABLE THE CONTROLLED PRESENTATION OF STIMULI WITH IN THE BOWL
• ENABLES ASSESSMENT OF THE VISUAL FUNCTION THROUGH OUT THE VISUAL FIELD
• DETECTION & QUANTIFICATION OF DAMAGE TO THE VISUAL FIELD
• MONITORING THE CHANGE OVER A TIME
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PERIMETRY TYPESKinetic Static
• measures extent of visual field by plotting isopters ( locus of retinal points having same sensitivity)
•Stimulus moves from non- seeing to seeing area.
•Result depends upon the experience of the operator.
• e.g, Goldman perimetry, confrontation, Tangent screen, Arc perimetry
• measures the sensitivity of each retinal points.
•The stimulus is stationary but increases in luminance.
• Mostly automatic, very little role of the operator.
•e. g, Automated perimetry, Goldman perimetry
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GOLDMAN PERIMETRY
• THE MOST WIDELY USED INSTRUMENT FOR MANUAL
PERIMETRY.
• HAS A CALIBRATED BOWL PROJECTION INSTRUMENT
• WITH A BACKGROUND INTENSITY OF 31.5 APOSTILBS (ASB),
• TEST TARGETS: DOTS
• VARYING SIZE AND ILLUMINATION
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PERIMETRY BOWL•BACKGROUND
LUMINANCE
31.5 ASB
RADIUS OF THE BOWL
30 CM Patient side
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GOLDMANN TARGETS• THE STIMULI (DOT) USED TO PLOT AN ISOPTER DENOTED
BY
• ROMAN NUMERAL, A NUMBER, AND A LETTER.
• ROMAN NUMERALS = 0 TO V (SIZE)
• NUMBER = 1 TO 5 (LUMINANCE) USE OF FILTER
• ALPHABET = A TO E ( ‘’) USE OF FILTER
V4e , I4e, IV3e
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GOLDMANN PERIMETRY: ROMAN NUMERAL
• SIZES OF STIMULI [0...V SCALE]
• EACH SIZE INCREMENT EQUALS
• A TWOFOLD INCREASE IN DIAMETER AND A FOURFOLD
INCREASE IN AREA.
Diameter (mm) Area (mm2)
0 0.28 1/16
I 0.56 ¼
II 1.13 1
III 2.26 4
IV 4.51 16
V 9.03 64
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TARGET ILLUMINATION
• LUMINANCE SETTINGS
• EXPRESSED IN UNITS CALLED APOSTILBS (CANDELA/M2)
• 2 SETS OF FILTERS – 5 EACH • 10 STEPS
• STANDARD VS FINE SETTINGS
• (1...5 AND A...E SCALES)
• 1, 2, 3, 4 SETTINGS REPRESENT 0.5 LOG UNIT CHANGES = 5 DB
• A, B, C, D AND E SETTINGS REPRESENT 0.1 LOG UNIT CHANGES = 1DB
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TARGET RANGE IN GOLDMANN
• MORE THAN 100 COMBINATIONS OF SIZE AND INTENSITY OF TEST
TARGETS ARE POSSIBLE
• BUT ONLY A FEW ISOPTER ARE NEEDED TO DEFINE THE VISUAL FIELD.
• SIZE “0” GENERALLY IS OMITTED
• BECAUSE RESULTS OF THE PLOTS ARE INCONSISTENT.
• THE FINE-INTENSITY FILTER IS USUALLY SET TO THE LETTER “E”
• WHICH ELIMINATES THE SMALL-INCREMENT LIGHT FILTERS.
• TEST TARGET : DENOTED BY – SIZE + (STD. + FINE) LUMINANCE
• EG: V4E, I4E, II3E
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SOME INTERESTING FACTS• A CHANGE OF ONE NUMBER OF INTENSITY
– IS ROUGHLY EQUIVALENT TO A CHANGE OF ONE ROMAN
NUMERAL OF SIZE I.E. III4E = IV3E
• ISOPTER PLOTTED WITH TARGETS OF EQUAL SUM OF
–ROMAN NUMERALS (SIZE) & NUMBER (INTENSITY)
• ARE CONSIDERED EQUIVALENT.
–FOR EXAMPLE,
• THE I4E ISOPTER IS ROUGHLY EQUIVALENT TO THE II3E ISOPTER.
• I + 4 = 5, II + 3 = 5
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STANDARD VF PLOT OF RE
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REQUIRED EQUIPMENT FOR VF MAPPING
•GOLDMANN BOWL PERIMETER
•LENS HOLDER
• RECORDING PAPER
•COLORED MARKERS
•PATCH FOR MONOCULAR TESTING
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GOLDMANN PERIMETER
Pantoscopic handle
Horizontal cut
Patient Side (Bowl)
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GOLDMANN PERIMETER
Patient Side (Bowl)
Fixation target
Chin rest
Head rest
Len Holder
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GUIDELINE TO PLOT
• FIRST DEMONSTRATE THE PROCEDURE TO PATIENT
• BY STATICALLY PRESENTING LARGE TEST
GENERAL RULES FOR PLOTTING “ISOPTERS”
• AN ISOPTER IS MAPPED FOR THE PARTICULAR STIMULUS SIZE AND INTENSITY
• MOVE FROM NON-SEEING TO SEEING WHILE PRESENTING STIMULUS
• MOVE AT A RATE OF 5 DEGREES PER SECOND INSIDE
• PRESENT KINETICALLY EVERY 15 DEGREES INTERVAL
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GUIDELINES FOR PLOTTING
• BEGIN IN THE FAR PERIPHERY AND KINETIC PLOT ISOPTER IN ALL
MERIDIANS
• USE A V4E, I-3E , I-2E OR TARGET (DEPENDING UPON AGE
• PLOT THE BLINDSPOT
• ONLY 4 MERIDIANS ARE REQUIRED( MORE IF IRREGULAR OR
LARGE)
• USE THE I-4E FOR THE BLIND SPOT
• WITHIN ISOPTER OF I-2E OR I-3E
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GUIDELINES•CENTRAL STATIC TEST WITH I-2E
• EXPLORE FOR ANY SCOTOMAS
• KINETIC PLOT WITH I-3E STIMULUS ONLY IN SUSPECTED DEFECT AREA
•STATIC TEST BETWEEN I-3E AND I-2E ISOPTERS
WITH THE I-3E STIMULUS (SCOTOMA SEARCH)
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GUIDELINES
• SPECIAL CASE PLOTS
• GLAUCOMA SUSPECTS
• PLOT MORE POINTS ALONG THE NASAL EDGE OF THE ISOPTER
• PLOT APPROXIMATELY
• EVERY 3-5 DEGREES,
• 15 DEGREES ABOVE AND BELOW THE HORIZONTAL RAPHE
REPEAT FOR CENTRAL, INTERMEDIATE AND PERIPHERAL PLOTS
• SUSPECTED NEUROLOGICAL LESIONS
• PLOT MORE POINTS ON EITHER SIDE OF THE VERTICAL MERIDIAN
• REPEAT FOR CENTRAL, INTERMEDIATE AND PERIPHERAL PLOTS
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RECORDING
• ALL RECORDING SHOULD BE DONE ON THE GOLDMANN RECORDING PAPER
• PATIENT NAME,
• DATE,
• RX USED,
• PUPIL SIZE,
• EYE TESTED AND
• PATIENT COOPERATION / FIXATION
• INDICATE THE TARGET SIZES USED IN THE BOTTOM RIGHT HAND BLOCK (COLOR MARKER)
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COLOR CODING OF ISOPTERS
• I-2E BLUE
• I-3E ORANGE
•I-4E RED
•II-4E GREEN
•III-4E PURPLE
•IV-4E BROWN
•V-4E BLACK
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EXPECTED FINDINGS FOR NORMAL ISOPTERS • PATIENTS UNDER 50 YEARS OF AGE
I. PERIPHERAL I-4E (SIZE=SAME, BRIGHTER LUMINANCE)
II. INTERMEDIATE I-3E
III. CENTRAL I-2E (SIZE=SAME, DIMMER LUMINANCE)
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EXPECTED FINDINGS FOR NORMAL ISOPTERS• PATIENTS 50 YEARS OR OLDER
I. PERIPHERAL II-4E (SIZE=LARGER, BRIGHTER LUMINANCE)
II. INTERMEDIATE I-4E
III. CENTRAL I-2E OR I-3E (SIZE=SMALLER, DIMMER LUMINANCE)
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INTERPRETATION
• THE VISUAL FIELD IS CONSIDERED ABNORMAL IF:
– THE THRESHOLD VALUES ARE SIGNIFICANTLY BRIGHTER (0.5
LOG UNITS OR MORE) THAN THE EXPECTED VALUES
AND / OR
– SCOTOMAS OR DEPRESSIONS ARE PRESENT
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SOME VISUAL FIELD DEFECTS
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SOME VISUAL FIELD DEFECTS
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BITEMPORAL HEMIANOPIARight eye Left eye
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AUTOMATED PERIMETRY ( STATIC)• MACHINE CONSTRUCTED ALONG THE BASIC LINES OF A
GOLDMAN PERIMETER + SOPHISTICATED SOFTWARE
PROGRAMS.
• KEY REASON FOR INCREASED INTEREST IN AUTOMATED
PERIMETRY HAS BEEN DUE TO THE STANDARDIZATION
AUTOMATED PERIMETRY ALLOWS.
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AUTOMATED PERIMETRY
• VISUAL THRESHOLD IS MEASURED AT A SERIES OF FIXED POINTS IN THE VISUAL FIELD.
• THE BRIGHTNESS OF THE TEST SPOT IS VARIED, BUT NOT ITS LOCATION.
• THRESHOLD IS USUALLY PLOTTED RELATIVE TO NORMAL FIELDS, TO REVEAL DEFECTS
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AUTOMATED PERIMETRY
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AUTOMATED PERIMETRY
• HUMPHREY:
• OCTOPUS:
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THRESHOLD DETERMINATION
Frequency of seeing curve
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THRESHOLD DETERMINATION
28dB
24 dB
32 dB
30 dB29 dB
0 dB brightest stimulus
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THRESHOLD DETERMINATION
• AGE MATCHED NORMAL DATA ARE USED TO COMPARE
PATIENT’S DATA
• NORMAL RANGE DETERMINED BY
• SENSITIVITY OF EACH RETINAL POINTS 10,000 INDIVIDUALS
• UPPER 95% AS NORMAL
• LOWER 5% AS ABNORMAL
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TESTING STRATEGIES
• OCTOPUS
• NORMAL
• DYNAMIC
• TOP ( TENDENCY ORIENTED PERIMETRY)
• HUMPHREY
• SITA (SWEDISH INTERACTIVE THRESHOLD ALGORITHM)
• SITA FAST
• FULL THRESHOLD
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DIFFERENCE BETWEEN OCTOPUS AND HUMPHREY (TEST PARAMETERS)
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FACTORS AFFECTING AUTOMATED PERIMETRY• BACKGROUND LUMINANCE
• STIMULUS SIZE
• FIXATION CONTROL
• REFRACTIVE ERRORS
• CATARACTS AND OTHER MEDIA OPACITIES
• MIOSIS
• FACIAL STRUCTURE
• FATIGUE
• EXPERIENCE OF A PERIMETER
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VALIDITY OF THE TEST
• FALSE POSITIVE RESPONSE
• > 20% UNRELIABLE
• FALSE NEGATIVE
• >20% UNRELIABLE
• SHORT TERM FLUCTUATION
• 1-3 DB NORMAL FLUCTUATION
• FIXATION LOSS
• >33% UNRELIABLE
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CHOOSING AN APPROPRIATE PROGRAM
EXAMINATION PROCEDURE
TEST PROGRAM(G1, G2, 32, M2)
+
TEST STRATEGY (NORMAL, DYNAMIC, TOP)
+
PERIMETRY METHOD( W/W, FLICKER, B/Y, KINETIC)
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PROGRAMS
G1/G2
• CENTRAL 30 DEGREE
• GLAUCOMA SCREENING
• 59 POINTS
• LOCATIONS MORE CLOSELY WITH TOPOGRAPHY OF RETINA
(IN AREAS OF CONCERN OF GLAUCOMA)
• 2.8 DEG SPACING
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PROGRAMS 32 ( GENERAL EXAMINATION)= 30-2 IN HUMPHREY
• INTRODUCED WITH EARLY AUTOMATED PERIMETRY
• 76 TEST LOCATIONS
• WIDE SPACING (6 DEGREES) ( NOT APPROPRIATE FOR
GLAUCOMA)
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PROGRAMS
MACULA PROGRAM(M2)
• CENTRAL AND PARACENTRAL VISUAL DEFECTS IN
NEUROLOGICAL AND MACULAR PROBLEMS
• CENTRAL 10 DEG
• 56 TEST LOCATIONS
• SPACING 2 DEGREES
• 0.7DEG SPACING IN THE MACULA
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PROGRAMS
LVC (CENTRAL LOW VISION)
• TO TEST HOW MUCH SENSITIVITY IS REMAINED IN THE
CENTRAL FOVEAL AREA.
• 77 LOCATIONS
• 30 DEGREES
• END STAGE GLAUCOMA
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STRATEGIES
• NORMAL STRATEGY
• STANDARD
• 4-2-1 BRACKETING PROCEDURE
• 10-15 MIN
• EARLY AND SHALLOW DEFECTS
• YOUNGER PATIENTS ( GOOD CONDITION IN ANSWERING THE
QUESTION TILL THE END OF A LONG PROGRAM)
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STRATEGIES
• DYNAMIC STRATEGY
• ONE THRESHOLD CROSSING
• SMALL STEPS IN REGIONS WITH NORMAL SENSITIVITY AND
LARGE TOWARDS DEPRESSED FIELD
• TEST DURATION REDUCED BY TWO
• ESPECIALLY WHEN FOCAL DEFECTS ARE EXPECTED
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STRATEGIES• TOP ( TENDENCY ORIENTED PERIMETRY)
• LIGHT SENSITIVITY OF THE RETINAL IS INTERRELATED RATHER
THAN HAVING AN INDIVIDUAL VALUE
• 2 MINUTES
• FOR PATIENTS WITH DEPRESSED FIELDS, FOR CHILDREN, ELDERLY
ONES WHO ARE NOT CAPABLE OF FINISHING A LONGER
EXAMINATION
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INTERPRETATION OF RESULTS
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DIFFERENT ZONES
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GREYSCALE
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VALUE TABLE
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COMPARISON /CORRECTED COMPARISON(TOTAL AND PATTERN DEVIATION)
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PROBABILITY PLOTS
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CUMULATIVE DEFECT CURVE
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GLAUCOMA HEMIFIELD TEST
• 5 SECTORS IN THE UPPER FIELD ARE COMPARED TO FIVE
MIRROR IMAGES IN THE LOWER
• IF VALUE IN TWO SECTORS DIFFER TO AN EXTENT THAT FOUND
IN
• <0.5% OF THE NORMAL POPULATION ( HIGHLY SENSITIVE)
• <1% OF NORMAL POPULATION (OUTSIDE NORMAL LIMIT)
• <3% OF THE NORMAL POPULATION (BODERLINE)
• <5% OF THE NORMAL POPULATION ( CAN BE A NORMAL PLOT)
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GLOBAL INDICES OCTOPUS
•MEAN SENSITIVITY (MS)
•MEAN DEVIATION (MD) (–2DB TO +2DB)
• LOSS VARIANCE (LV) (0-6DB)
•CLV(0-4DB)
• SF (1.5DB- 2.5DB)
•RF < 15%
HUMPHREY
• GHT
• MEAN DEVIATION
• PSD
• CPSD
• SF
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OCTOPUS CRITERIA FOR VISUAL FIELD DEFECT§
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HFA CRITERIA FOR VF LOSS
• PATTERN DEVIATION PLOT
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RECENT ADVANCES IN AUTOMATED PERIMETRY• GOLDMAN KINETIC MODULE• HIGH-PASS RESOLUTION PERIMETRY - USES THIN RINGS INSTEAD
OF SPOTS• SHORT WAVELENGTH SENSITIVE PERIMETRY - BLUE ON YELLOW
FOR S CONES• FLICKER PERIMETRY - FLICKERING TARGETS INSTEAD OF STATIC
FLASHES• AULHORN'S SNOW FIELD CAMPIMETRY - USES TV “SNOW” AND
POINTING• MOTION PERIMETRY - DETECT MOVING TARGETS INSTEAD OF
FLASHED ONES• RAREBIT PERIMETRY- USES VERY SMALL, BRIGHT SPOTS• PUPIL PERIMETRY - MEASURES PUPIL RESPONSES INSTEAD OF
SUBJECTREPORTS• MULTIFOCAL VEP - MEASURES CORTICAL EVOKED POTENTIALS
INSTEAD OFSUBJECT REPORTS
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SUMMARY
• PRINCIPLE OF KINETIC AND AUTOMATED PERIMETRY
• APPROPRIATE SELECTION OF VISUAL FIELD TESTING FOR A
PARTICULAR PATIENT
• ACCURATE INTERPRETATION OF VF REPORTS