College of Medicine and Health Science,

Department of Optometry

Interpretation of Humphrey and FDT VF results

Moderator:- Dr. Fisseha Admassu (ophthalmologist).

By:- Bekalu G.( MSc 2nd )

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 Outline

Introduction
Interpretation of Humphrey and FDT VF results
Summary
References

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 Objective

• After this seminar, we will

Interpret the Humphrey and FDT visual field printouts
and differentiate glaucomatous field defect from non
glaucomatous field defect

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 Introduction
• Field of vision is an island of vision in the sea of darkness.
• The limits of the normal field of vision are
– Superiorly and nasally 60°

– Inferiorly 70°
– Temporally >90°

• The island of vision has a steep central peak that

corresponds to the fovea, the area of greatest retinal
sensitivity.
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• Different patterns of visual loss are found with diseases of
the retina, optic nerve & central nervous system.
Purpose of VF test
- To determine the outer limits of visual perception
- Grading the difference of defect within VF
- For diagnosis of a disease

- Ascertaining the effects of therapy

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• Perimetry is the systematic measurement of visual field function.

 The two types of perimetry are

– kinetic and static perimetry.

• In kinetic perimetry
– a stimulus is moved from a non seeing area of the visual field to a
seeing area along a set meridian
– Locations in the visual field of equal retinal sensitivity will be
joined by an isopter.

E.g. Tangent screen, confrontation, Goldman perimeter

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• In static perimetry
– The retinal sensitivity at a specific location is determined by varying
the brightness of the test target.
– The size and location of the test target remain constant
– Objective and standardized with minimal perimetrist bias.

– A quantitative representation of the visual field can be obtained more

rapidly than with manual testing.
– Inclusion of statistical analysis software is the reason for the
widespread popularity of static perimetry.
E.g. FDT, Humphrey and octopus
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Frequency Doubling Technology (FDT)
– Portable (screening tool), relatively inexpensive instrument
designed for fast and effective detection of visual field loss
– Uses low SF sinusoidal gratings of white and dark bar light that
has high TF counter phase flicker

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– It has high sensitivity and specificity to early glaucomatous
defects, good patient acceptance, good reproducibility, but no
progression software available and not used for children's
– Can use the C-20 or N-30 patterns for screening or threshold
testing
– The screening test has -1 and -5 test protocols
– Up to -6.00D RE and cataract affects visual field result less

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•

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Humphrey visual field analyzer

An automated perimeter intended to identify visual field defects for

screening, monitoring and assisting in the diagnosis and management of
ocular diseases such as glaucoma & related neurological disorders.

Quantitative and standardized

algorithms
Diagnostic and progression statistics
available
Expensive and nonportable

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Interpretation of Humphrey & FDT VF printouts


A. Single field analysis


Patient's data and general information
Name

ID

Date of birth

Age

Eye tested

Time & date of examination

Test duration 13
Test parameters/test type
Screening or threshold--- for both VF analyzers

 In FDT

C-20 or N-30 for both screening and threshold testing

 In Humphrey

For threshold testing = Macular, Central 10-2, Central 24-2, Central 30-

2, Peripheral 60-4 & nasal step

For screening = central 40, 80,64,76, central armaly

= peripheral 60, nasal step, armaly FF, FF 81, 120,135, 246

Fixation monitor

Gaze/Blind Spot, off 14

Fixation target

Central, small diamond, large diamond and bottom LED

Stimulus size & color

Size= I, II,III, IV & V.

Color= white, blue &red

Background = 31.5 ASB

Pupil diameter
VA & Rx

Test speed:- Normal or slow

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Threshold Test strategies
– Full threshold
– Fastpac
– SITA fast
– SITA standard

Screening test strategy

• Two Zone

• Three Zone

• Quantify Defects
Screening Test Mode

 Age Corrected

 Threshold Related

 Single Intensity
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• In Humphrey, different STATPAC threshold Formats are
available
– Single field analysis

– Over view
– Change analysis
– Guided Progression Analysis

(GPA)

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 Reliability indices
To check patient' performance (reliability).

“XX” after scores that fall outside the reliability limits used in the
normative database.
In addition, STATPAC printouts include the message, “Low Test
Reliability” with excessive fixation losses and “Excessive High False
Positives” when the false positive limit has been exceeded.

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1. Fixation loss/error/
– Are printed as a ratio, such as “3/10”.
– Limits for SITA Standard and SITA Fast are 20%.

2. False positive errors

– Blank targets at 0% contrast are periodically tested to check if the
patient responds even when no stimulus is presented.
– ≤ 15% is the normal limit
– Subjects that are anxious or “trigger happy” tend to give high false
positive results.

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3. False negative errors
– are evaluated by presenting targets at maximum contrast (100%)
– There is no limit displayed for false negative errors with SITA
testing.

4. Gaze Tracking
– To determine how steady patient fixation was during the length of
the test.

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 Plots

1. Threshold sensitivity plot/number/

Shows the threshold contrast sensitivity (in HFA equivalent dB) at
each location
Basic information upon which all other analyses and print outs based
upon
When tested under photopic conditions, the normal visual field
demonstrates the greatest sensitivity centrally with sensitivity falling
steadily toward the periphery

The number of tested retinal points varies with the test parameter
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 A cluster of 2 or more points depressed ≥5 dB compared with

surrounding points is suspicious.

A single point depressed ≥10 dB is very unusual but is of less

value on a single visual field than a cluster, because cluster points

confirm one another.

Corresponding points above and below the horizontal mid- line

should not vary markedly

– Normally the superior field is depressed l- 2 dB compared with

the inferior field. ?? 22

 The threshold sensitivity result will be transferred into a
gray scale plot for generalized impression of the VF result

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2. Total Deviation Plot
– Shows whether the sensitivity for each VF location falls within
normal limits (compared to the age-matched normative database)
or whether the sensitivity falls below a probability of 5% to 0.5%
of the normal population.
– This plot is indicative of diffuse or generalized loss in sensitivity.
– The numeric values in the upper portion of these plots represent
the difference in decibels (dB) between the patient’s test results
and the age-corrected normal values at each tested point

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– The TD probability plot, translates the values from the upper plot into shaded
symbols which indicate the statistical significance of each dB deviation.
o These are explained in the legend labelled “Probability Symbols”.

o The darker the symbol the less likely it is that the field is normal in
that location

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3. Pattern deviation Plot

– Depicts localized sensitivity loss once the diffuse sensitivity

component is removed.
– Numeric Pattern Deviation plot shows the deviation in decibels
from the age corrected normal values, adjusted for any shift in
overall sensitivity.
– The pattern deviation probability plot indicates the statistical
significance of the result at each point.
• the darker the symbol the more significant the deviation from
the normal threshold value.
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Global indices

1.Mean Deviation (MD)

– the average elevation or depression of the patient’s overall field compared

to the normal reference field.

– If the deviation is significantly outside the population norms, a “p” values

of p < 10%, p < 5%, p < 2%, p < 1%, & p < 0.5% will appear in front of

the MD.

– A significant MD may indicate that the patient has an overall depression,

or that there is significant loss in one part of the field and not in others.

– MD is best interpreted in relation to the TDP and PDP

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2. Pattern Standard Deviation (PSD)
– A measurement of the degree to which the shape of the patient’s
measured field departs from the normal, age-corrected reference
field.
– A low PSD indicates a smooth hill of vision.
– A high PSD indicates an irregular hill and may be due either to
variability in patient response or to actual field irregularities.
– The statistical significance for PSD is indicated using the same
categories for “p” as with the mean deviation.

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3. Visual Field Index (VFI)
– VFI is a measure of the patient’s overall visual function as
compared to an age-adjusted normal population.
– It is a weighted average of the ratio of the measured threshold to
the age-adjusted normal threshold for all points that have
depressions in the Pattern Deviation at the 5% level or higher.
– Because it is based only on points that are significantly depressed
in Pattern Deviation, the VFI is relatively insensitive to visual field
changes due to cataract.

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– The VFI is weighted to give increased importance to thresholds
near the point of fixation, so that it is a good indicator of changes
in functional vision.
 The VFI for a visual field defect progressing toward the central
field will decrease more rapidly than the VFI for a defect that is
progressing along the periphery.

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Glaucoma hemifields test
– On 24-2 and 30-2 humphery tests, it evaluates 5 zones in the superior
field & compares these zones to their mirrored zones in the inferior field.
– Evaluates the severity of disturbed points in each zone pair, relative to its
normative database

Results:-
• Within normal limits
• Outside normal limits
• Borderline
• General reduction of sensitivity
• Abnormally high sensitivity.
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– To identify localized visual field loss occurring in a pattern typical of
that seen in glaucoma but not used for a disease other than glaucoma
– Fastpac tests will not display the GHT result

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A= GHT
B= TDNP &TDPP
C= PDNP &PDPP
D= Global indices

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Screening
Printout
Symbols

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B. Interpretation of a Series of Visual Fields
• Interpretation of serial visual fields should meet 2 goals:
– separating real change from ordinary variation

– using the information from the visual field testing to determine the
like hood that a change is related to glaucomatous progression

Methods
– Point-by-point analysis by hand

– Statistical programs
– Calculation and comparison of visual field indices

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• Separation of true pathologic progression from normal test-to-test

variability remains a difficult challenge.

• Test variability is part of the pathophysiology of glaucoma.

• A good baseline VF is required for interpretation of a series of VF.

– Up to 3x will be repeated for baseline VF

• Subsequent VF should be compared with these baseline fields.

– Any follow-up VF that appears to be quite different should be

repeated for confirmation of the suspected change from baseline.

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Progression guidelines:-
Deepening of existing scotoma suggested by the reproducible
depression of a point in an existing scotoma by ≥7 dB.

Enlargement of existing scotoma suggested by the reproducible

depression of a point adjacent to an existing scotoma by ≥ 9 dB.

Development of a new scotoma suggested by the reproducible

depression of a previously normal point in the visual field by
≥ 11 dB, or of 2 adjacent, previously normal points by ≥ 5 dB.
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• A general decrease in sensitivity may be secondary to glaucoma
or may be related to media opacity
– Two causes of general decline in sensitivity that may confuse
interpretation are variable meiosis & cataract

• Suspected new defects or progression of existing defects should

be reproduced on subsequent visual fields to determine their
validity.
• It is important to correlate changes in the visual field with those
of the optic disc changes

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• On Humphrey that have STATPAC
– Change analysis
– GPA are sensitive for assessment of possible progression

• Progression of glaucomatous VF loss generally occurs in areas

damaged previously.
• Scotomas become larger and deeper, and new scotomas appear in the
same hemifield.

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 Summary
Hold the two visual fields side by side

The results are highly subjective and interpretation should

incorporate other pertinent findings

Artifacts that will result false VF should be considered

• Try to look the reliability indices for checking test reliability

Repeat all first-time abnormal visual field results.

For the purpose of valid comparison, it is important to keep test

parameters consistent among different test visits for the same patient
During interpretation use the acronym “ WANDER”
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 References

Humphrey Field Analyzer II-i series User Manual

BCSC: chapter 3 clinical evaluation of glaucoma
Advanced diagnostic procedure power points on VF
Slide shares on FDT and Humphrey

YouTube

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THANK U!

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