Humphrey Visual Field

Interpretation
- Basic Glaucoma Course -

Elsa Gustianty
Dept of Ophthalmology - Padjadjaran University
Glaucoma Unit - Cicendo Eye Hospital
Bandung
Introduction

• Glaucoma is treated in order to preserve visual

function and quality of life.
• The standard measurement of visual function in
glaucoma has ben clinical perimetry for clinical
assesment of visual field.
• Visual field measures differential light sensitivity : the
abililty of the retina to distinguish a stimulus that is
some degree brighter than the background illumination

AAO, section 10.

Werner Eliot. Visual Field in Glaucoma. In Yanof Myron , Ophthalmolgy.2nd ed. Saint Louis: Mosby.2004
Island of vision
• Harry Moss Traquair: “visual field is an island hill
of vision in a sea of darkness”

Alward WL, Krachmer JH. Glaucoma the requisites in Ophthalmology. Mosby.2000

• By convention, the visual field is plotted as the patient
sees it

From: Ritch R et all, The Glaucoma,2nd ed, 1995

Definition and limits of visual field
• Visual field is part of the • The visual field is
environment that is measured in two ways:
visible to the fixing eye. kinetic and static
perimetry

From: Ritch R et all, The Glaucoma,2nd ed, 1995

Anderson DR, Patella, Automated static perimetry,
2nd ed 1999
Advantages of an automated static perimeter

• S tandardized and reproducible

• More sensitive to subtle defect
• Availability of numeric data for interpretation and comparison
• Less perimetrist training and skill

Alward WL, Krachmer JH. Glaucoma the requisites in Ophthalmology. Mosby.2000

Disadvantages of static automated perimetry

• More challenging and frustrating for the patient

• Has a distinct learning curve
• Higher retest variability in area of moderate and severe
visual loss
• Fixed test grid size
 Units of light intensity

• The light intensity expressed in apostilb (asb) units

or decibel (dB) units.
• Attenuation of light is expressed in logaritmic,
in tenths of log units, which called decibels.

• No attenuation by filters so it is labeled as 0 decibel

• 10 decibel is 1/10 less intense than maximum stimulus
• 20 decibels is 1/100 less intense than masimum stimulus
• 30 decibels is 1/1000 less intense than maximum stimulus
• 40 decibels is 1/10.000 less intense than maximum stimulus
Heijl A, Patella VM. E ssensial perimetry.3rg ed. California: Zeiss
 Goldman Octopus Humphrey
1.2.3
Background
illumination
31.5 asb 31.4 asb 31.5 asb
Maximum stimulus
intensity
1.000 asb 4.000 asb 10.000 asb

• Apostilb are absolute units (same in all instruments)

• Decibels are relative units
(depend on maximum intensity by each perimeter)

• For example:
0 dB in Goldmann is 1.000 asb
0 dB in Humphrey is 10.000 asb
 0 10.000

10 1000 Brightest light

20 100

30 10

40 1

50 dB 0.1 asb Dimmest light

As the dB value is decreasing, the light intensity is increasing

• The lower the decibel value,
the lower the sensitivity.
• The higher the decibel value
the higher the sensitivity.
 Definition of threshold
• Threshold sensitivity is defined as the stimulus intensity
at which the patient respond 50% of the time
Selection of point-pattern

30-2 central pattern 24-2 central pattern

Number test points : 76 Number test points : 54
300 from fixation point 240 from fixation point
Distant between points is 60 Distant between points is 60
10-2 central patten
Number of test points : 68
100 from fixation point
Distant between points is 20
 Advance Field Defect
Macula program
Number of test points : 16
30 from fixation point
Distant between points is 20
 Split fixation
Fundamental standard program

• 30-2 central threshold with size-III stimulus

• Thresholding algorithms: full threshold or S ITA standard
• White on white
How is the normal range determined?

• We test normal people and measure their retinal sensitivity

at each location tested.
• Decide upper 95% values in normals are normal
• The lower 5% values in normals are abnormal.
• Remember that abnormal is not the same as diseased.

• E xample:
If glaucoma prevalence is 1% and we performed perimetri
on 100 random people.
We would expect 6 abnormal field, 1 due to glaucoma and 5
who are labelled as abnormal because fall in the lower 5%.
 ............continued
• The machine doesn’t know the situation
• We know it since we have all the clinical information
• Automated fields need interpretation and clinical
correlation
• This is why no smart computer can replace human
experience

Thomas R , George R . Indian J Opthalmol 2001,49,2:125-40.

Purpose of the test
1. Determine whether the field is normal.
2. If it is abnormal, whether the abnormality
is due to glaucoma.
3. Determine the extent of visual loss
4. Determine whether or not it is progressive.

Werner E liot. Visual F ield in Glaucoma. In Yabof Mtron , Ophthalmolgy.2nd ed. S aint Louis: Mosby.2004

In this basic session we will discuss about 1,2,3

Interpretation of Single Field Analysis
• We recommend to interpret the field systematically in
8 section
1
Zone 1 : Patient’s data
Zone 2 : Reliability criteria
2
Zone 3 : Grey scale
8
3 Zone 4 : Total deviation plot
4 5 7 Zone 5 : Pattern deviation plot
6 Zone 6 : Global index
Zone 7 : GHT
Zone 8 : Raw score
Zone 1 : Patient’s and test data

• Patient’s data : Name, right or left, Date of Birth,

Pupil diameter, VA, RX
Age

• Test data : fixation monitor, fixation target,

colour stimulus, background illumination
stimulus size, test pattern, testing strategy
 Patient variables
• Age : Interpretation of data by statpac is age dependent
Decreased sensitivity with age
Increase in fluctuation in periphery greater with age
Increase in variability in repeated test greater with age

• Pupil size : 3-4 mm (spontaneous pupil size is the best)

Constricted pupil < 2 mm : edge scotoma
Constricted pupil with media opacity : significant effect
Should not be dilated unless there is a clear reason.
But for disc evaluation the patient may be dilated
As long as pupil size is consistent with the baseline.
Anderson DR , Patella VM. Automated static perimetry. 2nd ed. Mosby.1999
Refractive correction
• With stimulus size-III, refractive correction < 1D best
ignored.
• It is best to use the weakest lens
• Cyl 0.5 – 1.00 D : spherical equivalence
• Not need a lens for:
1. S ph -3.00 D of any age
2. Have not undergone cataract extraction
3. Have not been given cycloplegic
4. Young enough to use their accomodation comfortably
during examination

Anderson DR, Patella VM. Automated static perimetry. 2nd ed. Mosby.1999
Foveal threshold

• Foveal threshold preferably turned ON

• Correlate visual acuity with foveal threshold.
• VA good but FT low : early damage to the fovea
• FT good but VA low : perhaps needs refractions
Zone 2 : Reliability Indices

If above certain percentage the machine will flag ….XX

Patient Fixation loss ... > 20%

False Positive errors… > 33%
False negative errors… > 33%
Methods for fixation monitoring
• Blind spot indicated by small triangle below the horizontal
median, 15° temporal to fixation.
• 5% of stimulus will be presented on the blind spot,
the patient respont to stimulus is due to shift of fixation
The Gaze Monitor
• Full -time two- variable gaze monitor
• Using image analysis to locate the center of pupil and
corneal reflection
• Upward deflection : full scale indicate >100 fixation error
• Downward deflection : blinking
 Exemplar
Mostly OK
y
Frequent signal
loss

Shaky at the
beginning

OK

Very bad
Courtesy of dr. Chandra Sekhar, LVPEI
False Positive Errors
• Patient push the response
button to the non projected
stimulus but at random.
• If it is > 33% , in grey scale
there may be a scattered
very light areas or
white scotomas.
 False negative errors
• Failure to response when a visible stimulus is presented.
• Due to fatique, hysteria, lack of attentiveness, hypnosis.
• Grey scale : cloverleaf pattern
• FN should not be considered unreliable particularly if
there is agreat deal of patology.
• If the machine flag the indices, indicating that the patient
has low reliability criteria.

• Low patient reliability does not necessarily mean that

the field will provide no useful information.

• It is just that such field were not included in the database,

such field must be interpreted with more caution.

Thomas R, George R. Indian J Opthalmol 2001,49,2:125-40.

Zone 3 : Gray Scale
• The retinal sensitivity from
0-50 dB value are divided into
10 groups
• The conversion of raw data to
gray scale does not involve
any statistical calculation.
• Do not make any diagnosis
base on gray scale.
Zone 3: Gray Scale........
• Give impression of dangerous curve
• Usefull in gross high FP and high FN
• To explain condition to the patient
• Quickly glance at zone 3 and
move to zone 4, 5, 6, 7 and 8.
Zone 4: Total Deviation Plot

Numerical plot

Probability plot
4

P< 5% indicates retinal

sensitivity in that point is
seen in < 5% of normal
population
P < 2% ...etc
 It is a point by point
Zone 8
difference of the patient’s
threshold from those
expected in age corrected
normals.
Normal
value

22- (-3)=25 If less than normal

negative sign is given.

Positive sign means

better than normal value.

Zone 4
Zone 4: continued....
•
• Normal hill of vision
•

• Depression of hill of vision

• Total deviation plot highlight this deviation

• Total deviation plot draw to any overall sinking
caused by media opacities : cataract, refractive errors,
corneal opacities, miosis.
Thomas R , George R . Indian J Opthalmol 2001,49,2:125-40
Zone 5: Pattern deviation plot
Numerical plot
Probability plot

P< 5% indicates retinal

sensitivity in that point is
seen in < 5% of normal
population
P < 2% ... etc
Zone 5 : Continued...
-8 + 3 = -5

•Only point of 24-2 pattern are considered: 51 locations

•Take the 7th highest point (-3)
•The 7th best point becomes zero by adding +3 (-3 + 3 = 0)
• Add +3 to all value in total deviation to became pattern
deviation
Zone 5 : continued...

• Total deviation convert to pattern deviation to

bring out deep scotoma.
• Try to look for abnormal points in a cluster.
• If there are abnormal points in total deviation that
persist in the pattern deviation  scotoma
Thomas R , George R . Indian J Opthalmol 2001,49,2:125-40
Normal Hill of vision
Zone 4: normal no depressed point
Zone 5: normal no depressed point

(courtesy of Prof. Ravi Thomas)

Generalized depression (cataract)
Zone 4: many depressed point
Zone 5: normal
No localized defect
(courtesy of Prof. Ravi Thomas)
Localized scotoma
There are depressed point in zone 4 that
persist in zone 5
(courtesy of Prof. Ravi Thomas)
Zone 6: Global Indices

E ach global index summarized

and characterizes one aspect
of the test as a single value

S ITA : MD and PS D

Full Threshold :
MD, PS D, S F, CPS D
Zone 6 : Global Indices
Mean Deviation (MD)
derived from Total Deviation plot.

Pattern Standard Deviation (PS D)

is standard deviation of MD.

S F is intratest variation in 10
predetermined point, it shows
reliability and variability.

Corrected PS D (CPS D), PS D

corrected by S F
Zone 7: Glaucoma Hemifield Test

Five possible message of GHT

• Outside normal limit
• Borderline
• General reduction of sensitivity
• Abnormally high sensitivity
• Within normal limits
Zone 7: GHT..cont’d
• In the GHT,
five zones in the upper
field are compared its
mirror-image in the lower
Field
Zone 7 : continued
• Outside normal limits
1. Upper zones compare to lower zones, at least
one sector pair’s score difference must
exceed that found in 99% normal pop.
2. Individual score in both members of any zone
pair exceed that found in 99.5% normal pop.

• Borderline
Upper and lower zones, at least one zone pair difference
exceed that found in 97% normal pop
• General reduction in sensitivity
Neither of the condition of “outside normal limit” is met,
but if the best part of the field is depressed to an extend
that occur in < 0.5% normal population.
• Abnormally high sensitivity
In the best part of the field to be higher than found in
99,5% of population.
• Within normal limit
Non of 4 conditions is met.
Zone 8: Raw test result

• Actual threshold value

• E ven if all zones are
normal, but the clinical
picture are very suspicious
inspect zone 8.
• One may pick up a scotoma
• 0 indicates absolute scotoma
Is This Glaucoma?
Confirmation of early glaucoma field defect :

1.Pattern deviation probability plot shows a cluster of > 3

non-edge points with p< 5% and one points has p<1%.

2.PS D or CPS D with p< 5%

3.GHT outside normal limits

• If clinical features strongly indicate glaucoma, even one
criteria is good enough to make diagnosis.

• If the clinical features are not suspicious at all, all three

criteria must be positive.

• Repeat the field and look at the disc before making

diagnosis.
 How Advance is the Disease?
E arly defect
1. MD index better than -6 dB
2. Fewer than 25% points in total deviation probability plot
a defective at the 5% level
3. Fewer than 10 points are defective at the 1% level
4. No point in the central 5° has a sensitivity < 15 dB

Moderate defect
E xceed one or more criteria of early defect but does
not meet the criterion to be severe.
S evere defect
1. MD worse than 12 dB
2. More than 50% points in total deviation probability plot d
epressed at the 5% level
3. More than 20 points depressed at the 1% level.
4. A point in the central 5° with 0 dB OR
5. Points closer than 5° of fixation has sensitivity
< 15 dB in both lower and upper hemifields.
 Some artifacts that affect the result
E xamination artifacts Patient artifacts
• Technician • Misunderstanding the test
• E quipment • Fatique
• Test type • Inattentiveness
• S oftware • Mental status
• Systemic illness
E ye artifacts
• Refraction Analysis artifacts
• Pupil size • Misinterpretation
• Fixation • Requires standards normal/
• Media opacity fluctuation
 Instruct the Patient
• Most important part • Blinking
• Follow the manual • Response button to pause
• Demonstrate the test the test
• Human touch • Foveal threshold and
• Offer encouragement fixation target
• Don’t expect to see all • Other pitfalls
stimuli
• Don’t hurry; machine
slows down for you

Courtesy of dr. Chandra Sekhar, LVPEI

Case Discussion
Small Pupil

GR Reddy, A visual Field Evaluation with Automated Devices

 Improper Correction

GR Reddy, A visual Field Evaluation with Automated Devices

Wrong Entered Patient’s Data
• Zone 1:
not enterered corectly
Left eye  right eye

 Always check zone 1

 Repeat the test
Case 1 : Cataract
Zone 1 : entered correctly
Zone 2 : reliable field
Zone 4: many depressed point
with p<0.5%
Zone 5: depressed point is not
persist here
Zone 6: MD – 7 dB (abnormal)
Zone 7: general reduction in
sensitivity

No localized defect
General reduction because of
cataract
Case 2: Glaucoma
Zone 1: Entered correctly
Zone 2: Reliable field
Zone 4: depressed point p<0.5%
in superior area
Zone 5 : many depressed point
persist with p< 0.5%
Zone 6 :MD and PSD flag as
abnormal
Zone 7: GHT outside normal limit

Moderate defect
Case 2: Moderat defect glaucoma
Case 3:

Zone 1 : entered correctly

Zone 2 : Relaible field
Zone 3 : central island
Zone 4 : depressed point in nasal
superior area
Zone 5 : persist
Zone 6 : MD and PSD flag as abN
Zone 7 : GHT outside normal
limit

Superior arcuate scotoma

Case 3:
Case 4 : Advanced glaucoma
Zone 1 : entered correctly
Zone 2 : false neg NA
Zone 3 : central island
Zone 4 : all depressed point
Zone 5 : better than deviation plot
Zone 6 : MD and PSD flag as abN
Zone 7 : GHT outside normal limit

Advance field loss

Order for 10-2 and macula program
Case 5

• Zone 1 :
not filled completely
• Zone 2 :
reliable field
• Zone 3 :
central island
• Zone 4:depressed point with
• p<0.5% all over
• Zone 5: inferior hemifield loss
incomplete sup arcuate
• Zone 6: MD dan PS D flag as
abnormal with P<0.5%
• Zone 7: GHT outside normal limit

• Advance damage
• POAG + Cataract
with cd rat 0.9, post trabeculectomy
Case 6 : High False negatif

• Zone 1: entered correctly

• Zone 2 : unreliable field
• false neg 99%
• Zone 3 : clover leave pattern
• Zone 6 : MD and PS D flag as abno
rmal
• Zone 7 : GHT outside normal limit

High False negative

Advice: repeat the test
Case 8: High False Positive
• Zone 2: Unreliable field due to hi
gh FL and high FP
• Zone 3: white scotoma
• Zone 4 and 5: Pattern deviation i
s worse than total deviation
• Zone 6: MD + (positive)
• Zone 7: High sensitivity
• Zone 8 : Impossibly high sensitiv
ity

E xcessive false positive

Trigger Happy Patient
Repeat the test
Case 9 : Choreoretinitis
Zone 1: filled correctly
Zone 2: reliable field
Zone 4: depressed point p<0.5% in
inferior area
Zone 5 : depressed point persist
Zone 6 :MD and PSD flag as
abnormal
Zone 7: GHT outside normal limit

Inferior hemifield loss

is it due to Glaucoma?
• Disc finding: thinning of
superior rim

Retinochoroid scar
(Chorioretinitis in
superior area )
Case 10 : ... Incorrect position