Humphrey Visual Field Tests: A Workshop For Beginners.: Natalio J. Izquierdo, M.D

Humphrey Visual Field Tests:
A workshop for beginners.
Natalio J. Izquierdo, M.D.

Presidente Electo Asociación Médica de PR
Introduction
 VF defects due to glaucoma

 Gold Standard Dx & Tx
 Full Threshold versus SITA
 Owner’s Manual
 My interpretation format
Page 4
Single Field Analysis
Page 7
Top of the Page
 Patient data
 Reliability indices
 Numeric results
 Gray tone results
Page 8
Lower Half of the Page
 Total deviation plot

 Pattern deviation plot
 Probability symbols
 Global Indices
 EOM (SITA)
Page 9
Patient Data
 Which eye?
 Patient’s name; ID; DOB
 Strategy & Stimulus
 Pupil size & Date
 VA & Refraction
Page 10
Reliability Indices
 Fixation losses
 False positives
 False negatives
 XX = unreliable
Page 11
Reliability Indices: Fixation Losses
 Pt did not fixate

 Losses per stimuli
 Exceed 20%
 XX sign
Page 11
Reliability Indices
Example 1
 Quantify Losses
 Is it Reliable?
Page 11
Reliability Indices
Example 2
 Quantify losses
 Is it reliable?
Page 11
Reliability Indices: False Positives
 40 points rechecked & >40dB

 Movement & Sound
 Answers without stimuli?
 XX sign when 15 - 33%
 Low reliability message
Page 12
False Positives Example 3
 If ≥ 40 dB in Numerical Threshold
 White in Gray tones graph
Page 12
Reliability Indices: False Negatives
 Shows a bright stimulus in an area

of known sensitivity.
 If Pt does not respond a False
Negative
response is recorded.
 Unreliable if > 33%
Page 13
False Negatives’ Causes
Inattentive patient
 Poor fixation
 Physical Condition
False Negatives
Example 4
Page 13
False Negative
Example 5
Page 14
Reliability Messages’ Summary
 XX = Unreliable
 If Fixation losses > 20%
 If false positives > 33%
 If false negatives > 33%
Reliability Clinical Pearls
Test is unreliable if:
 Full 30-2 takes > 550 questions

 Full Threshold lasts > 20 minutes
 If SITA lasts > 6-8 minutes
Pages 15-16
Example 6: Questions Asked
Page 15
Example 7: Test duration
Page 16
Gray Tone Threshold Printout
 10 shades of gray tone symbols
 Each tone represents dB changes
 0 dB Highest intensity
 Not in SITA
Page 17
Threshold Test Printouts
 Blind spot shown as a triangle in the
Numeric Threshold Printout
Page 18
 Numeric grid gives

thresholds in dB
 Rechecked if 5 dB
+/- than expected

 Rechecked value is
shown within ( )
Page 19
Example 9
Page 19
 < 0 = pt did not see stimulus at 0 dB
 0 = pt saw the stimulus at 0 dB
 Example 10
Page 20
Glaucoma Hemifield Test
Compares
upper & lower
hemi-fields
Page 21
Glaucoma Hemifield Test
 Identifies localized VFD as abnormal

 Within / Outside / Borderline
 Reduction or High Sensitivity

GHT Within Normal Limits
Example 11
Page 22
GHT Abnormal
Example 12
Page 23
GHT Borderline
Example 13
Page 24
GHT Reduction of Sensitivity
Example 14
Page 25
GHT High Sensitivity
Example 15
Page 26
Total deviation Plot
 Left Lower Half

 Upper: Numeric values
(Patient vs normal)
 Lower: Probability
(darker is less likely to
be normal)
 Color symbols as %
Page 28
Total deviation Plot
 Example 16
 < -5?
 Black squares?
Page 28
Pattern Deviation Plot
 Right Pair
 Adjusted for cataracts
 Shades = Probability
 Example 17
Page 29
Global Indices
 Far Right Side

 Mean Deviation (MD)
 Pattern Standard Deviation (PSD)
 Short-term Fluctuation (SF)
 Corrected Pattern Standard Deviation
Page 30
Global Indices
 Far Right Side
Page 30
Global Indices: Mean Deviation
 Average depression or elevation of a

Patient versus normal
 Normal = -2 to 2 dB
 If significantly outside population
normal a p value is given (p < 0.5%)
Page 30
Global Indices - Mean Deviation
MD Values (dB) Description
-2 to 2 Normal
-2 to -6 Mild
-6 to -12 Moderate
-12 to -16 Severe
< -16 Profound
Page 31
Example 17: ↓ MD
Page 31
 Example 18
 MD?
 Describe
 P value
Page 31
Example 19 - ↑ MD
Page 32
Global Indices:
Pattern Standard Deviation
 Pt’s VF departs from nl

 Normal: 0 to 4 dB
 Low PSD = smooth hill of vision
 High PSD = irregular hill
Page 33
Global Indices: PSD
 Example 20
 High PSD =
irregular hill
Page 33
Global Indices:
Short Term Fluctuation (SF)
 Index of consistency
 Points Tested twice
 Normal 0 to 2 dB
 Example 21: 3.20 dB
Page 34
Global Indices:
Corrected Pattern Standard Deviation
 How the shape of the pt’s hill of vision deviates

 Unreliable responses
 VF losses or
 Both
 Normal 0 to 4 dB
 Example 22
Page 35
Section 2
VF 2.1
Page 37
VF 2.2
Page 39
VF 2.3
Page 41
VF 2.4
Page 43
VF 2.5
Page 45
Progression: 5-7-9-11 @ Pattern
 New depression = 2 adjacent points ≥ 5 dB

 Deepening of an existing point ≥ 7 dB
 Enlargement with an adjacent point ≥ 9 dB
 Develop a new scotoma ≥ 11 dB
Page 48
Change Analysis Printout
 Box plot:
Median,
Elongation
 MD
 PSD
Page 49
Patient 3.2
Page 51-54
Patient 3.3
Pages 55 - 58
Neuro vs Glaucoma VFD?
 ON appearance
 Vertical Meridian
 Congruous
 Quad vs Hemianopsias
Page 60
Neuro vs Glaucoma: MRI?
 History
 Vertical
Meridian
 Bitemporal Hemianopia
 Quadrantanopsias
Page 60
Mrs. Rose
Page 61
Conclusions
 VF needed for Dx & Tx
 Single Field Analysis
 Progression
 Change Analysis
 Glaucoma vs Neuro
Thank you and Allergan

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Humphrey Visual Field Tests:

A workshop for beginners.

Natalio J. Izquierdo, M.D.

 VF defects due to glaucoma

 Total deviation plot

 Pt did not fixate

 40 points rechecked & >40dB

 Shows a bright stimulus in an area

 Full 30-2 takes > 550 questions

 Numeric grid gives

+/- than expected

 Identifies localized VFD as abnormal

 Reduction or High Sensitivity

 Left Lower Half

 Far Right Side

 Far Right Side

 Average depression or elevation of a

 If significantly outside population

normal a p value is given (p < 0.5%)

-12 to -16 Severe

< -16 Profound

 Pt’s VF departs from nl

 Low PSD = smooth hill of vision

 High PSD = irregular hill

 How the shape of the pt’s hill of vision deviates

 New depression = 2 adjacent points ≥ 5 dB

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