VISUAL FIELDS IN GLAUCOMA

• Perimetry is d clinical assessment of the

VF
• It serves in [a] Identifying abnormal fields
ie. Making diagnosis. [b] Quantitative
assessment of normal or abnormal fields
during follow-ups
• Some methods may be better in diagnosis
than follow-up and vice-versa
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 Automated Static Perimetry
• Standard in d last 2 decades
• Newer ones are:
• Short-wavelength automated perimetry
[SWAP],
• High-pass resolution perimetry,
• and frequency-doubling technology[FDT]
perimetry

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 PATTERNS OF NERVE LOSS
• The hallmark is the nerve fiber bundle
defect. Possible defects are:
• Generalized depression
• Paracentral scotoma
• Arcuate or Bjerrum scotoma
• Nasal step
• Altitudinal defect
• Temporal wedge
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 Patterns Cont’d
• The superior and inferior poles of the optic
nerve appear to be most susceptible to
glaucomatous damage.
• Double arcuate scotoma, may occur,
resulting in profound peripheral vision loss
• Typically, the central island of vision and
inferior temporal VF are retained until late
• The pt and the perimetrist can bring
variables into the result – it is subjective
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[L]Normal view, [R] Glaucomatous
view

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Normal view vs Tubular vision

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 INTERPRETATION
• First assess quality.
• Percentage of fixation losses, the false
+ves & false –ves
• Damaged areas demonstrate more
variability than normal areas.
• Glaucomatous damage may cause an
increase in false-negative responses
• All this will be used to assess pts reliability
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 ABNORMALITY
• Normal VF show greatest sensitivity
centrally, falling steadily toward the
periphery
• Study the Humphrey or Octopus field
machine generated numerical data.
• An abnormal pattern deviation has greater
diagnostic specificity than a generalised
loss.
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INTERPRETATION OF A SERIES
OF FIELDS
• Should meet 2 goals:
• [a] Separating real change from ordinary
variation [b] To determine the likelihood that a
change is related to glaucomatous progression.
• This is made easier with a good baseline, this is
why a reliable field is obtained early
• Progression of existing defects or suspected
new ones should be reproducible on subsequent
examinations to establish their validity.

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 CORRELATION WITH OPTIC
DISC
• If no correlation other causes of visual loss
should be considered eg. ION, pituitary tumor,
demyelinating or other neurologic disease,
especially in d following situations
• -Disc less cupped than indicated by field
• -Disc pallor is more than cupping
• -Progression of field loss seems excessive
• -Pattern of VF is uncharacteristic
• -Field defect does not correlate with disc
abnormality
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 STAGING
• After determining the presence of the
disease visual field examination is used to
stage the disease.
• Shallow / isolated field defects are
characteristic of early glaucoma,
• whereas extensive deep deficits,
encroaching fixation are characteristic of
late or end stage glaucoma
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 INTERPRETATION Cont’d
• In patients with mild / moderate glaucoma
visual field examination is usually to
determine if disease progression has been
halted.
• This would also hold true for patients with
advanced glaucoma.
• In advanced glaucoma, assessing fixation
characteristics is important to plan ahead.
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 How often should the fields be
done ?
• Though there is no consensus guidelines
do exist.
• (1) If the results of the field test are
sufficient to confirm the diagnostic
conclusion, fields may be repeated at least
once more (36).
• A change in therapy on the basis of a
single abnormal visual field test is only
rarely appropriate.
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 FOLLOW-UPS
• Ocular hypertension : Establish a
baseline and perform followup fields
• on the basis of degree of risk for
developing glaucoma.
• Patients with low IOP, negative family
history, or optic nerves that appear
healthy, test every one or two years.
• Patients with unstable high IOP or other
risk factors, every 3-6 months.
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 FOLLOW-UPS Cont’d
• Stable glaucoma : Initially every 6-12
months.
• Patient compliance needs to be kept in
mind.
• Visual fields by measuring the cumulative
damage are sensitive to detect
progression
• especially when IOP appears to be well
controlled (assessment of compliance).
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 FOLLOW-UPS Cont’d
• Unstable glaucoma : One can ask for
several fields within a span of few months.
• This would hold good people who have a
relative contraindication to surgery.

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