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.

 Inverted logarithmic scale with 0dB=brightest stimulus. . Not standardized.  Decibel is a relative scale created by manufacturers of automated perimeters to measure sensitivity.Apostilbs Vs decibels:  Lumininance of test targets is measured in an absolute unit. apostilbs.

 Total deviation :difference between patient’s threshold measured and value expected in age matched normals. .

p value. 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. +ve in Octopus. dB.Global indices:       Mean deviation: mean difference between sensitivities of age matched normals and subject. Highlights overall depression. . PSD can be normal when there is a diffuse loss. Indicated as: -ve in Humphrey. STATPAC.

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

which is not caused by SF.e.5dB. threshold at 10 predetermined points.error excluded.       . 1-2. Cataract. twice. Statistical probability of a threshold value measured at a point that exists in age-matched normals. pathology.  CPSD: extent of focal loss in the visual field.   SF: Intratest test variability. Comparison on a point by point basis. ref.  Probability analyses: symbolic represenation. Retinal condition. Darker the symbol lower the probability. SD – SF indicator of patient’s consistency. taking short term fluctuations in account i.

Does not analyze temporal nerve fibre bundle defects.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.

 higher than 99.  .  5%  Abnormal high sensitivity.Inference:  Outside normal limits.0.  <1%.  3%  Abnormally low sensitivity.  Borderline.5%.5% Within normal limits.

kinetic. Static mode.  . constant upgradation of the software on the basis of clinical feedback from the ophthalmologists. newer models .5asb.  Most popular. Background illumination-31. consistency of basic hardware. The machine: Viewing distance-33cms.Basics of the Humphrey field analyser: Projection type automated static perimeter.

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

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

Interpretation of visual field:  Recognise artifacts:  Reliability.  Assessment of damage. .

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

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

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

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. Cloverleaf defect due to high FN. Reason may be a tired patient.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. A high FN rate may or may not be reliable.

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High fixation loss may indicate. . Mislocation of the blind spot. FN rates and STF are low. then the high FL can be discounted. centre of blind spot was slightly mislocated. If two baseline fields are similar it can again be discounted. If FP.Fixation losses:       Not all fixation losses represent true loss of fixation. Macular disease.

good reproducibilty high (≥ 3dB) SF-poor reproducibility . low (≤2dB) SF.Short term fluctuations:  Testing option. shows variability of patients response over a single test period.

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. or  A cluster of three or more non edge points in a location typical for glaucoma.Minimum Criteria for Diagnosing Acquired Glaucoma:  A Glaucoma Hemifield Test outside normal limits on at least two fields. .

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

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

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

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2.expansion of pre existing defect. 4.entire field develops decreased sensitivity.new defect.Recognition of progressive damage:     1. .deepening of pre exisiting defect. 3.

.How would u approach?  Compare baseline field to each individual field  Study the entire series.

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

.Glaucoma change probability programme:       Point by point probability of any change in baseline field and new field.expansion : 3. cluster. Within 15° of field-2 previous normal points. p<5%.deepening of pre existing defect: part of a scotoma.new defect: 3 or more non-edge points each of which.5%. 3. 1.on two consecutive fields. Outside 15° of field-3 previously normal points depressed with p. 2. p<5%.

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

Gupta . .Parrish.Anderson.K.References:     Illustrated Automated Static Perimetry G. Testing of the Field of Vision-Douglas R.R.Doughlas R. Visual Field Examination-A.Charu Tandon. Clinical Decisions in Glaucoma-Elizabeth Hodapp.Anderson.Reddy.Richard K.Chaudhary.Reena M.

.Thank you..