Terminology

Visual Fields
· Visual field (VF) - all the space that one eye can see at any given instant
· Perimetry – the study or measurement of the VF
· Perimeter – an instrument designed to assess the VF

Normal VF
· Monocular extent
o VF is recorded from the pt’s perspective
o Restricted by orbital bones
o Primary vs secondary gaze
· Binocular extent
o Horizontal extent of 200o; right and left VFs overlap for
approximately 120o
o Vertical extent of 135o

Island of Vision
· The sensitivity of the eye is not consistent across all points in the visual
field. This is because the distribution of rods and cones in the retina
varies.
· Sensitivity varies with
o Eccentricity
o Adaptation level
o Nature of test stimulus
· Island of vision is represented by a 3D diagram wherein
o X-axis – horizontal extent of field
o Y-axis – vertical extent of field
o Z-axis – sensitivity to light at that point in the visual
field
· Cone density does not decrease linearly across the retina, it
follows the gradient of the hill which is
o Steeper nasally than temporally
o Steeper superiorly than inferiorly
· Sensitivity across the VF changes as lighting level
changes.
o Light adapted – expect more cone sensitivity and less
rod sensitivity, vice versa for dark adapted.
o Darker conditions will be relatively favourable for
peripheral vision
· Contour lines (isopters)
o Represent points of equal sensitivity
o Useful in 2D VF representation

· · Hill of Vision (HOV)

o 2D vertical section through an Island of Vision
o 3 stages
 0-5o – steep slope at the fovea
 5-40o – flatter central VF
 >40o – steep edge of VF
Representing Visual Fields (2D)

Indications for VF assessment

· Glaucoma or suspicion of glaucoma
· Reduced visual acuity
· Unexplained headaches
· Neurological disorders e.g., RAPD, multiple sclerosis, optic neuritis
· Benign optic disc conditions
· Retinal disorders e.g., inflammations and dystrophies
· Medications e.g., Plaquenil
o Plaquenil or hydroxychloroquine – used to prevent or treat malaria caused by mosquito bites. Ocular side
effects include bull’s eye fundoscopic appearance, decreased VA, missing central vision, blurred vision, light
flashes, metamorphopsia, retinal toxicity, and more.
· Assessing fitness to drive
· Evaluating sport fitness esp. at elite levels

Advantages and disadvantages of VF examinations

Advantages Disadvantages
· Direct assessment of visual function · VF machines are not portable
· Assesses more than just central vision · Equipment (VF machine) is expensive
o Periphery · Time consuming to perform
· Non-invasive · Subjective assessment by patient
· Malingering and cheating can be detected o May be unreliable
· Repeatable
· Good for monitoring progression
· Good for evaluating differential diagnoses
o Characteristic VF losses in disease
· Medicare – separate item number

Visual Field Assessment – Classifications

· Manual
o Amsler Chart
o Confrontational
o Tangent
· Automated
o Humphrey and Medmont
o SWAP
o Flicker perimetry
o FDT
o HPR
o mERG

· Kinetic (Dynamic)
o A stimulus of constant size and shape is moved across the VF. Typically, the stimulus is moved from the
periphery until seen. This procedure is repeated along a series of meridians, to map the VF.
o E.g., tangent screens, Goldmann bowl, confrontational fields
o Kinetic has largely been replaced by static means of testing.
· Static
o Objects of varying sizes and shapes remain fixed in position across the VF, but luminosity or size varies.

· Each testing methods have their own advantages and disadvantages.

· Ideally, we as clinicians, want to detect anatomical changes as early as possible.
o Histological studies have demonstrated that up to 50% of retinal ganglion cell (RGC) fibres may be damaged
before a VF defect is shown using standard automated perimetry.

Manual
Confrontational Fields
· Gross method used to screen for the presence of unsuspected VF defects
o Performed as part of routine clinical examination
o Gross therefore, not very sensitive
· Involves comparing the visual field of the pt to that of the practitioner
o Assumes practitioner’s VF is normal
o Set-up/ procedure
 Practitioner is seated in front of the patient.
 Pt covers one eye (left) and focuses on the practitioner’s eye or nose.
· Practitioner may elect to cover their eye (same side as the pt’s)
 Test is performed equidistance between patient and practitioner
· Testing methods
o Target confrontation
 Dynamic movement of a small target into VF until it is seen
 Visibility (order) – white > red > green and large > small e.g., 5mm white target ≈ 15mm red target
o Finger wriggling
 Dynamic movement of fingers into VF until it is seen
o Finger counting
 8 or sometimes 4 static field locations

Tangent/ Bjerrum Screen

· Simple, easy, and inexpensive test that is more sensitive than confrontation fields
· Set-up
o Non-reflective black screen
o Small central white fixation target
o Concentric circles stitched at 5o intervals
o A selection of targets
· At 1m (front screen), up to 25-30o from central fixation can be evaluated
· Target is kinetically moved from the periphery until it is just visible and then moved into central fixation to check
for scotomas
 o Findings are transferred manually on to a paper sheet
o Black pins are used on the screen to indicate missing points/ areas not seen

·
C

ongruous VF loss – same defect in both eyes (occipital and

posterior parietal regions)
· Incongruous VF loss – different defect in each eye (anterior
parietal and optic tract lesions)

Amsler Grid/ Chart

· Square-shaped grid used to detector or monitor
metamorphopsia or scotoma involving the central visual field
in various disorders of the macula and optic nerve head.
· Indications for use include
o Evidence of or reason to suspect macular damage
 Macular degeneration
 Diabetic maculopathy
 Central serous retinopathy
o Unexplained loss of visual acuity
o Use of drugs predisposing pt to maculopathy e.g.,
Tamoxifen or chloroquine
 Tamoxifen or Nolvadex is a selective estrogen
receptor modulator used to prevent and treat breast
cancer in women and men. Ocular side effects
include blurred vision, decreased VA, vortex
keratopathy, retinotoxicity, and bilateral optic
neuritis.

Goldmann Bowl Perimeter

· A stimulus is projected onto the surface of a bowl and this stimulus can be
kinetically moved. The location and movement of the stimulus is controlled by the
practitioner.
· A stylus which moves in conjunction with the stimulus can mark the visual field
extent on a pre-printed chart paper.
 Manual/ Kinetic Visual Field testing – Advantages and
Disadvantages
Advantages Disadvantages
· Fast and flexible · Requires an experienced clinician
· Excellent in severe VF loss or measuring · Not a standardised procedure
absolute loss · Not good for measuring the depth of a
· Excellent in low vision and neurological scotoma
cases · Cannot pick up shallow scotomas well
· Good for multihandcapped · Not good at quantifying central field

Automated
Humphrey Visual Field Analyser (HVFA)
· All-in-one instrument which tests sensitivity for specific points in the
peripheral visual field
· Considered the gold-standard for testing visual fields
· Many different types of visual field tests may be conducted
o Screening (supra-threshold)
o Threshold
· Patient is required to respond by pressing a button when they see the stimulus
appear
o The stimulus may be a variety of colours, sizes, and intensities
· Humphrey VF is sensitive to the patient’s fixation
o Tests are performed to ensure fixation (gaze-tracking)
o In-built camera for practitioner to monitor fixation

Medmont Automated Perimetry

· Replication of the Humphrey VF Analyser
o Instrument is connected to a PC, not an all-in-one instrument.
o Software (PC) replicates the output of the HVFA
· Can be integrated into the Medmont studio
o Program which integrates other information e.g., retinal images
Short Wavelength Automated
Perimetry (SWAP)
· Decreased sensitivity to short-wavelength (blue) light in
glaucoma
o Selective damage theory – ganglion nerve fibres
conveying short wavelengths have a larger axon
diameter
o Redundancy theory – blue cones (~15%) are much less
Yellow-adapted retina
prevalent than red and green
· Hence, testing sensitivity to blue light should be more
sensitive to glaucomatous changes
o However, short wavelengths, blue-sensitive-cones are only
marginally more sensitive than red and green ones therefore
 A yellow background is used to de-sensitise red and green cones
 A blue stimulus is used on a yellow background.
o The stimulus is large due to relative insensitivity to blue light.
· SWAP measures the sensitivity of the blue sensitive visual pathway
(Koniocellcular)
o Koniocellular pathway (10%) – blue information
o Magnocellular pathway (10%) – flicker or motion
o Parvocellular pathway (80%) – colour and form
· Existing machines e.g., Humphreys, Medmont, and Octopus are able to
perform SWAP testing
· SWAP testing is capable of detecting glaucomatous change up to 5-years earlier than standard white-on-white
testing. However,
o SWAP is more likely to be affected by lens opacities – yellowing of the crystalline lens absorbs blue light
therefore, making the pt less sensitive.
o There is increased variability in SWAP results, this is due to the larger test stimulus.
o SWAP requires a longer testing time than white-on-white

Flicker Perimetry
· Relatively greater loss of magnocellular fibres in glaucoma
o Magnocellular fibres have a greater axon diameter and are less prevalent
o A flickering light is presented, and detection relies magnocellular transmission
· Pt detects whether the light is constant or flickering
· Two methods
o Critical fusion frequency (CFF) – frequency of flicker is varied (with constant contrast). Threshold is the
highest frequency at which flicker can be detected.
o Temporal modulation perimetry (TMP) – contrast is varied (with constant flicker frequency). Threshold is the
lowest contrast at which flicker can be detected.
· Performed using existing machines e.g., Medmont and Octopus.

Frequency Doubling Technology (FDT)

· Based on the ‘Frequency Doubling Illusion’
o Sinusoidal grating of low spatial frequency (0.25 cycles/ degree)
undergoes rapid counterphase flicker at high temporal frequency
(25 Hz)
o Stimulus appears to have twice the spatial frequency
o Illusion is mediated by the magnocellular pathway (My cells)
 Fibres have a large axon diameter and are understood to be
selectively damaged in glaucoma
 Cells also have low redundancy (15 –
25% of magnocellular fibres and 1.5
– 2.5% of all RGC)
· Square gratings are presented across different
locations in the visual field, Frequency doubling technology
 o Two versions:
 Generation 1 – 10o stimuli in 17 locations
 Generation 2 – 5o stimuli in 69 locations
o Gratings are presented briefly, up to 720 ms
o Spatial and temporal frequency remains the same, the pt simply reports if they can see the stimulus
 Screening – grating contrast, depending on pt’s age, is held constant for less than 1 minute/ eye
 Threshold – contrast of the grating is caried
o Methods are not affected by blur (tolerates up to 6 – 7D), external room illumination, or pupil size (minimum
2 mm)
· Results are comparable to SWAP

High-pass Resolution (HPR)/ Ring Perimetry

· High-pass resolution filtering removes low spatial frequencies
o Requires greater resolution of a target rather than just the recognition of a light
· Pt detects the presence of a ring
o Core of the ring is brighter and the inner and outside edges are darker
o Threshold is the smallest possible ring that can be resolved
· Advantages
o Good sensitivity and specificity compared to white-on-white
o Considerably faster
o Good for monitoring disease progression

Multifocal Electroretinography (mERG)

· An electrophysiological means of testing VF
o Records electrical activity from 500 to 100 areas of retina
 Electrodes are placed near the cornea or striate cortex
· Only objective method of assessing VF – pt observes a screen pattern and the electrical response of the retina is
assessed
· Rarely used b/c pts don’t like electrodes and its utility as a clinical test is largely unknown

Humphrey Visual Field

Analyser
Strategy vs Test
· Strategy – given each location, this determines how the actual sensitivity is measured
· Test – determines the locations in the visual field that will be tested e.g., how far out the stimuli will be presented,
and how far apart they will be spaced

HVFA tests
· Screening tests
· Threshold tests
· Specialty tests

HVFA Screening Tests

· Screening tests typically tests whether points are seen
o These points are 6dB brighter (suprathreshold) than the threshold
· Screening strategies include
o Two zone – the quickest strategy; all point tested are reported as seen or not seen
o Three zone – any points in the VF which are missed are retested at maximum intensity and therefore reported
as a relative or absolute defect
o Quantify defects – any points in the VF which are missed are retested for their threshold value
· There are many (at least 12) screening tests available
o Tests have names with a number which specify the number of points tested e.g., Central 40, Central 76
o The extent of the VF tested ranges from 30 – 87o

HVFA Threshold tests

· Strategies for finding the visual threshold
o The exact threshold cannot be measured; some methods will produce a result closer to the true threshold than
others. However, there is usually a trade-off between test time and accuracy.
o All strategies share some characteristics
 Randomisation of stimulus test locations – prevents the pts from predicting the next stimulus
 Incorporation of estimates of fixation losses – used to estimate the pt’s reliability
· False positives – gaps where no stimulus is presented but the pt still presses the button
· False negatives – stimulus is presented at an intensity above a known threshold; ensures that the pt
responds to obvious presentations
· 4 strategies:
o Full-threshold
o Fastpac
o SITA Standard
o SITA Fast

1. Full threshold (4-2 dB)

· Previously, full threshold was considered gold standard for threshold perimetry.
· Initially, threshold is measured at four locations – one in each quadrant 9 o away from the fovea.
o This information is used to calculate the initial stimulus presentation based on the patient’s age
· A ‘two reversal staircase’ I used with the step-size reduced from 4 to 2 dB following the first reversal
· Threshold is measured as the dimmest light seen and testing time is approximately 12-15 minutes per
eye.
 2. FASTPAC
· One-reversal strategy and a single step-size of 3 dB
o Strategy is to present half of the initial stimuli (bright enough to be seen, and too-dim)
o Threshold is the dimmest light seen
o FASTPAC was developed to reduce the testing time; 2/3rd of the time taken for a full-threshold test
however, the trade-off is that the measured threshold is less precise.

3. SITA
· Swedish Interactive Threshold Algorithm (SITA)
· Strategy uses
o Prior knowledge – uses knowledge of the nature of field losses to better set starting testing levels and
reduce the number of presentations required.
o No false positive trials – relies on patient response time rather than leaving gaps to evaluate false
positives. Response times falling outside of normal ranges are used to estimate false positive rate.
o Rate of stimulus presentation – SITA adjusts the presentation rate according to the patient’s response
rate as opposed to using a constant rate of stimulus.
· SITA has a reduced testing time without compromising sensitivity and repeatability; patient driven
adaptive algorithm.
· SITA Standard
o Designed to have an accuracy similar to or better than 4-2 testing
o Takes approximately half the time of 4-2 testing (approximately 7 minutes)
o Gold Standard for perimetry testing especially in glaucoma diagnosis and monitoring
· SITA Fast
o Designed to have an accuracy similar to or better than FASTPAC
o Takes approximately half the time of FASTPAC testing (approximately 3-4 minutes); most rapid
threshold algorithm on HVFA.
o Good alternative to screening tests and for patients who cannot maintain attention.

· Threshold tests, numerical names e.g., 30 – 2

o 30 refers to the extent of the visual field tested – VF tested is 30 o out from the fovea
o 2 refers to the testing protocol i.e., the positioning and layout of the spatial grid.
 Protocol 1 – testing points are located on the horizontal and vertical axes
 30 – 1 refers to a 71-point grid which falls on the H & V axes
 24 – 1 refers to a 56-point grid which falls on the H & V axes
o Disadvantage is spacing; leaves a 6-degree bare area of test points surrounding fixatio

 Protocol 2 – testing points straddle the horizontal and vertical axes

 Preferred option due to 3-degree gap (compared to 6-degrees) around the macula
 Tests on either side of the midline and there are a greater number of test points in 30 degree field
  Many conditions respect the midline therefore, Protocol 2 is more commonly used as we are interested
on the results on either side.

o 10-2
 68-point grid with points spaced every 2o
 Useful for testing the macula and advanced glaucoma
o 24-2
 54-point grid, testing 30o nasally, with points spaced every 6o
 Useful for glaucoma and optic nerve head testing
o 30-2
 76-point grid with points spaced every 6o
 Useful for glaucoma, retinal, and ONH testing
o 60-4
 68-point grid measuring from 30o to 60o
 Can be combined with 30-2 for overall field 0-60o
 Useful for testing retinal changes and glaucoma
o Macula
 16-point grid with points spaced every 2o
 Tests only up to 5o from the fovea
o Nasal step
 Tests up to 60o from the fovea, focussing on the nasal midline
 Tests for a common sign of glaucoma

HVFA Speciality Tests

· Designed to test for specific defects e.g., glaucoma, binocular tests, superior tests.

Test Selection
· Selecting the most appropriate test
o Is there a reason to suspect a VF defect?
 FHx
 VA
 Confrontational fields
o Is there a need to test far periphery?
 Would 24-2 or 30-2 be sufficient?
o Has a VF test been performed previously?
 You may wish to repeat the same testing procedure (progression)
o Will the pt have the necessary attention to complete a threshold test?
o How much time do you have?
· The issues that need to be resolved/ addressed will guide test selection
o Standard white on white (WoW) or a specialist test?
o Screening or threshold?
o Central or peripheral?
o Full-threshold or fast-threshold?
o Standard test parameters?
o Foveal threshold – on or off?

· 24-2 with SITA standard is generally the test of choice unless there is a reason to select an alternate test
o 24-2 with SITA standard detects the majority of problems affecting central vision, and is appropriate for
determining the differential diagnosis of vision loss
· If there is a disease present, or reason to suspect it may be present, which
o Affects the retinal periphery e.g., retinitis pigmentosa, CMV retinitis, retinal detachment
 Use full-field testing, out to 60o
 Screening may be sufficient if you want to just track the extent, rather than test sensitivity
o Affects the macula e.g., age-related macular degeneration, drug toxicity
 Use central vision testing e.g., 10o, 24o, or 30o
 Threshold testing will best monitor changes
o Glaucoma
 Early or suspected glaucoma – 24-2 threshold testing
 Advanced glaucoma may only leave the pt with central vision – 10-2

Conducting the test

· Physiological factors
o Environmental – illumination, equipment, examiner, technique
o Ocular – retinal adaptation, refractive state, media, pupil size
o Global – age, fixation, reaction time, fatigue
1. Patient set-up
Patient
o Canthus mark
 Alignment ensures pt’s is in viewing through primary gaze position on fixation
o Chin is fully in chin rest
 If it is too far back, you may find a superior scotoma
o Forehead is against the rest
 If it is too far back, you may find an inferior scotoma
 You may choose to tilt the head back slightly if the pt has a prominent brow
o Pt comfort
 Posture – back and neck
Correcting Lens
o Lens selection
 Retinal defocus will result in reduced luminance and a magnification of the target
 This will cause a depression of overall sensitivity and the effect will be less pronounced for the
periphery
  Distance correction is required if,
 Refractive error >0.75D
 Cylinder >0.75D
 Presbyopes require an appropriate add
 Young patients who are dilated may require a small add e.g., +1.50D
 Using the pt’s own specs may be a good idea if,
 The field of view is bigger than a trial lens
 The specs are appropriate for near correction
 They are single vision lenses
o Lens placement
 Full aperture lens
 Properly positioned
 Pt is looking through the centre of the lens in primary gaze
 The lens is close to the pt’s eye as practical
 Sphere and cyl
 Ensure the sphere is closest to the pt
 Correct cyl axis
 Positive cyl may allow for a thinner combination of lenses to be used e.g., +3.00/-3.00 x 90 with
+3.25 Add
 Clean lens
 Disposable CL may be a better option for correction of high ametropia esp. hyperopes
Eyelids
· Conditions affecting the eyelids may influence VF e.g., ptosis (droopy eyelids) or blepharochalasis (inflammation
of the eyelids causing lid oedema and laxity)
o May result in superior field effects
· Upper eyelid can be taped to prevent VF defects

2. Clear and consistent instructions

· Clear pt instructions will increase the reliability of results

· Advise pt to press the response button down (long press) if they need to blink or relax

3. Correct data entry

· Ensures validity of test results
· Correct name, date of birth
· Pupil size >3mm
· Correct VA entered and refractive error

4. Fixation monitoring
· Practitioner observation
o In-built camera allows practitioner to monitor eye movements
o Most accurate means of monitoring
 · Blindspot monitoring – Heijl-Krakau method
o A number of presentations will be made at the pt’s blind spot to check for fixation
 If they pt is fixating correctly, they should not be able to see any observations presented at their blind
spot.
 If a presentation is seen at the blind spot, it is inferred the pt is not fixating.
o VF results/ printouts will record this as fixation losses. This will be given as a fraction of presentations
where the target was seen.
 20 – 33% fixation losses is considered too high
o Disadvantages
 Only intermittently samples fixation; not constant
 Increases the examination time
 Unlikely to detect small fixation errors
· Infrared optical monitoring
o Infrared lights monitor corneal movements and is used to calculate eye movements
 Presents the time course of eye movements and blinks
o Difficulties differentiating fixation losses and patient adjustments (horizontal movements)

· The perimeter will attempt to locate the blind spot at the beginning of the test, if this does not work, do not
turn fixation monitoring off. Look for the cause, typically it is because
o The patient is not fixating
o The fellow eye is not occluded
o The wrong eye is being tested
· Reasons to turn off fixation monitoring
o Patient has a small optic disc and hence a small blind spot
o The test is a first run i.e., learning experience

5. Be aware of peripheral problems

· Human factors
o Anatomy
 Lids, lashes, prominent brow
 Spinal problems, arthritis, large persons
 Consider a tangent screen
o Learning effect vs fatigue
 Performance in VF test improves with experience
 Increased sensitivity and decreased variability
 Different categories
 Gradual increase
 No improvement
 Large increase from 1st to 2nd test, then plateaus
o Fatigue
 Difficulty maintaining attention usually results in decreased sensitivity or increased fluctuations
 Normal, minimal: 1 – 1.5 dB
 Glaucoma pts: up to 6 dB
 Fatigue effect is dependent on
 Examination strategy – threshold vs screening
 Verbal feedback
 Patient state
 Reduce fatigue through verbal encouragement and rest periods

HVFA common errors

· Troubleshooting summary
o Incomplete or incorrect data entry
 o Incorrect trial lens power or position
o Dirty trial lens or CL
o No eye patch or wrong eye patched
o Pt not pressing response button
o Lights on
o Adaptation – walked in from outdoors (photopic)

Visual Field Results

Interpreting VF Results
· Test details
o Type of test
o Target characteristics
o Background intensities
o Testing strategy
o Test duration
· Left image below is a single field analysis which compares the results of a single threshold test with
o Age-corrected normative data and
o Highlights any sensitivity values or patterns that deviate significantly from the normal

· · Reliability indices
1. Fixation Losses
o Detected by presenting the stimuli in the blind spot
o >20% – start to doubt the results
2. False Positives
o Respond when no stimulus is present
o High fraction, >15 – 33%, suggests a trigger-happy patient
3. False Negatives
o Failure to respond to a bright stimulus, 9 dB brighter than previously seen at the same location
o High fraction, >15 – 33%, indicates inattention or advanced visual field loss
· Sensitivity measures
1. Numeric data
o Threshold values in decibels are arranged in the
spatial locations of the test grid
o Higher numbers represent greater light sensitivity
o A value of 0dB reflects the brightest stimulus
generated, often 10 000 asb
o A value <0dB indicates that the brightest stimulus
was not seen
2. Grey-scale diagram
o Sensitivity values are banded into categories,
typically 5 dB
o Darker shades indicate lower sensitivity
o Good diagrammatic representation but provides no
measure of how this relates to the expect results

· Total deviation
1. Sensitivity values
· Compares the measured sensitivity to age-matched normal on a point-by-point basis
2. Probability plot
· Provides a likelihood/ probability that the sensitivity at each point is below normal
expectations
· Compares the sensitivity to the age-matched confidence interval

o Total deviation is sensitive to diffuse visual field losses e.g., it will detect diffuse loss in juvenile cataract

· Pattern deviation
o Adjusts for a generalised depression e.g., media opacities, optical defocus, pupillary miosis
1. Sensitivity values
o Compares the measured sensitivity to the adjusted hill of vision on a point-by-point basis
2. Probability plot
o Provides a likelihood/ probability that the sensitivity at each point is below the adjusted hill of
vision
o Will be sensitive to the detection of focal visual field losses e.g., will detect focal loss above any generalised
depression
· Global Indices
o Summarise the results into a single statistical measure
1. Mean deviation (MD)
o Weighted average deviation from the normal reference visual field
o Thought of as a measure of overall height of the island of vision when
compared to an age-matched normal
o Negative MD represents a loss in sensitivity
 o Caused by generalised loss, or one small area of large depression
2. Pattern Standard Deviation (PSD)
o Weighted standard deviation of the differences between the measured and normal reference VF at each
location
o Describes non-uniformity in the height of the VF
o Small if diffuse loss and large if focal loss
o p < 5% will appear if either MD or PSD is statistically below normal

Mean Deviation Pattern Standard Deviation Interpretation

Normal Normal Normal
Abnormal Normal Generalised loss of sensitivity
Normal Abnormal Small, localised defect
Abnormal Abnormal Large defects and localised component

The following are available on full-threshold, Fastpac, and as an option on Medmont

3. Short-term fluctuation (SF)
 A measure of intra-test variability when threshold is repeated during a single field examination
 If a location is tested twice, the second value will appear in brackets below the first. The average of the
two values will be used for calculations.
 Scotomas will produce greater variability and hence a higher value may be indicative of a pathological
field defect.
4. Corrected pattern standard deviation (CPSD)
o PSD corrected for SF
o An index which is sensitivity to focal loss and may separate real deviations from those which are just due
to variability

o SITA adjusts threshold for variability therefore, SF and CPSD are not calculated
o p < 5% will appear if either SF or CPSD is statistically below normal

· Glaucoma Hemifield Test (GHT)

o Aims to decide whether field loss is compatible with a diagnosis of glaucoma
 10 sectors are chosen to represent the nerve fibre distribution
 5 above and 5 below the midline, mirroring each other
 The sum of pattern deviation probability scores is calculated for each sector
 Difference is calculated between the mirroring sectors
 5 classifications:
1. Outside normal limits – large difference in at least once sector of comparison
2. Borderline – moderate difference in at least once sector of comparison
3. General reduction in sensitivity
4. Abnormally high sensitivity
5. Within normal limits
 Visual Field Defect
A point or cluster of points of decreased sensitivity that is
repeatable.
Normal vs. Abnormal results
· Considerations
o Patient factors – first exam/ experience, understanding
o Artefacts – trial lens rim, eye lids & brows, refraction scotoma, wrong fixation target, dim light bulb
· Abnormal – Humphrey VF
o Glaucoma hemifield test is abnormal
o Pattern standard deviation is abnormal (p<5%)
o Pattern deviation plot
 Single point is p<0.5%
 Two clustered points are p<5% and at least one point is p<1%
 Three or more clustered points worse than p<5% and pattern of loss is consistent with ocular pathology
· Functional field loss
o Malingering (conscious)
 Deliberate – significantly high false negatives
e.g., 60%
 Contraction of the field – tunnel vision
 Exposed by altering the test distance
o Hysteria (unconscious)
 Highly suggestive
 Contraction of field and spiral kinetic field
 Reliability indices are not helpful

Referral
· Based on VF
o Repeatable VF defect
 And consistent with other clinical findings
 Unexplainable repeatable defect
 o Relevant pathology without VF defect
o Documented progressive field loss
· Common referral mistakes
o Referral based on one VF especially if there are no other clinical findings
o Failure to comprehend the learning effect i.e., VF improves based on pt’s experience
o Fatigue effects on the second eye
o Pseudo superior defects

HVFA Guided Progression

Analysis
· VFI is an overall marker of VF loss, similar to
MD but accounts better for generalised
depression
o % of useful vision patient has left
o Scales from 100% for normal to 0% to
perimetrically blind
o Provides another indicator for progression

Definitions
Visual Field Defects
· Visual field defect
o Any departure from the normal topography of the island of
vision
· Diffuse visual field loss
o Depression
o Often caused by pre-retinal opacities e.g., corneal oedema,
cataract
· Focal visual field loss
o An area of reduced sensitivity surrounded by an area of normal
sensitivity; represents a focal point of damage in the retina e.g.,
a retinal hole or haemorrhage or the visual pathway
 Relative scotoma – an area of reduced sensitivity
 Absolute scotoma – an area of complete loss of sensitivity
· Visual field contraction
o Caused by conditions which affect the peripheral retina e.g.,
retinitis pigmentosa, glaucoma, toxic effects of some drugs
· Descriptors:
o Density – relative vs absolute loss
o Type – focal, generalised, or contracted
o Location – central, peripheral, foveal, centrocecal
o Size – large, small, degrees & disc diameters
o Extent – total vs partial
 o Position – temporal, nasal, superior, inferior, R/L
 Altitudinal – exclusively superior or inferior
o Laterality – unilateral vs bilateral
o Macula sparing
o Shape – sectorial, hemianopia, quadrant, regular/ irregular

Visual Field Projection

· Visual field – represents the patient’s perspective i.e., as they see vs retinal
image
o Superior field corresponds to inferior retina
o Inferior field corresponds to superior retina
o Temporal field corresponds to nasal retina
o Nasal field corresponds to temporal retina
o Blind spots represent the temporal projection of the optic nerve

The Primary Visual Pathway

Primary Visual Pathway
· Nasal and temporal retina dissociate to different cortical hemispheres
· Retinal area is on the opposite side to the area of visual field it corresponds to
· The pattern of visual field loss provides a good indication for the location of the lesion in the visual pathway
Retinal Lesions
· Retinal anatomy is important when considering the visual field defect; the extent of damage to the different layers
will affect the visual field lost
o Light must pass through the inner layers first to reach the cones and rods located in the outer retina
o The ganglion cell axons form the nerve fibre layer which passes along the inner surface of the retina to the
optic nerve head where it takes a 90o turn to pass along the optic nerve

· Retinal nerve fibres follow a characteristic pattern across the retina to the optic nerve head
o Nerves from the macular area pass straight to the optic nerve head, forming the papillomacular bundle
 This bundle contains approximately 1/3rd of all the retinal fibres
 Temporal fibres arch around the papillomacular bundle to reach the optic nerve head, forming arcuate
bundles
 Superior, inferior, and nasal fibres pass straight to the optic nerve head
 Superior and inferior nerve fibres do not cross the midline but instead forms a line of demarcation called
the horizontal raphe (temporal)

o Observation of the retinal nerve fibres

 May be seen as fine silver shining striations
 More obvious in darkly pigmented fundus e.g., Asian or African populations
 Best seen using a red-free filter
 Death of retinal nerve fibres e.g., glaucoma leads to a darker appearance
· Retinal disease and visual field characteristics
o Inner retina – overlaps with optic nerve defects
 Defects follow ganglion cell distribution
 Respects the horizontal midline
 Commonly glaucomatous damage
o Photoreceptors
 Irregular VF loss
  Commonly rod and cone dystrophy
o Outer retina
 Monocular field loss
 Does not respect the horizontal midline or follow ganglion cell distribution
 Commonly RPE damage e.g., in AMD
· Inner Retina
 Damage to the nerve fibre layer will follow the nerve fibre distribution pattern
 Scotomas typically respect the retinal, horizontal midline
o Sector scotoma or defect e.g., in vascular occlusion
 Damage to a large bundle of nerve fibres
 The VF loss will reflect the pathway for that bundle of nerve fibres
 May be altitudinal defects, arcuate nerve fibre bundle scotomas, central
scotomas, paracentral scotomas, and segmental peripheral constriction
 Vascular occlusion VF loss may cross the midline if central nerve fibre Sector Scotoma
bundles are affected or if haemorrhages block the retinal tissue
o Arcuate Scotoma e.g., glaucoma
 Damage to a specific bundle of nerve fibres
 Field loss will reflect the pathway for the bundle of nerve fibres
 May be classified as an optic nerve head defect

o Centroceal scotoma e.g., toxic amblyopia

 Typically, bilateral, and common cause is tobacco-alcohol nutritional amblyopia
 Often features colour dyschromatopsia – deficiency in the perception of colours.
 Damage to the anterior visual pathway through toxins or malnutrition e.g., lack of vitamin A or B, and
alcohol poisoning
 Damage to the papillomacular bundle (does not respect the midline)
 May be classified as an optic nerve head defect
 Primary lesion may originate in the retina, chiasm, or optic tracts; not necessarily localised to the
optic nerve head
 Accompanied by colour dyschromatopsia
· Photoreceptors
 Density of photoreceptors vary across the retina:
 Fovea – maximum cone density
 Mid-periphery – maximum rod density
 Damage to the photoreceptors may result in irregular field
defects however, field defects will typically reflect any
observable fundus retinal changes
o Retinitis Pigmentosa
 Damage to the photoreceptors and retinal pigment
epithelium (RPE)
 Constricted fields
· Outer retina
 Damage to the photoreceptors or RPE
 Typically, monocular and does not respect the
horizontal midline or follow nerve distribution
 Field defects will typically reflect any observable
fundus retinal changes
o Central scotoma or defect e.g., maculopathy
 Damage at the RPE
  May be a relative or absolute defect
o Large monocular scotoma/ defect e.g., retinal detachment
 Retinal detachment occurs when the neurosensory
retina separates from the underlying retinal pigment
epithelium. The resulting damage does not follow
the nerve fibre bundle and therefore, does not
respect the horizontal meridian.
 Typically, correlates with visible lesion
 Detectable with confrontational fields

Optic Nerve
· Summary
o Approximately 1.2 million nerve fibres leave the retina at the optic nerve head (2mm diameter).
o The corresponding location of the nerve fibres in the optic nerve changes as the nerve progresses towards the
chiasm.
o Defects will typically reflect the nerve fibres that are affected.
· Tilted optic disc
o Congenital defect where the optic disc appears tilted to the nasal side as opposed to the temporal side
o Typically, bilateral and may result in a relative temporal defect
that resembles an early chiasmal lesion. The defect does not
necessarily respect the vertical midline and is thought to result
from diffuse hypoplasia of the optic nerve especially inferior
nasally.

Tilted disc
· Papilledema
o Non-inflammatory swelling of the ONH caused by raised intracranial pressure
o Presents bilaterally as an enlarged blind-spot
· Anterior ischaemic optic neuropathy

o Loss of blood supply to the optic nerve causing damage to all or part of the nerve
o Results in:
 Swelling and haemorrhaging and leads to optic atrophy once swelling has
resolved.
  Reduced visual acuity and altitudinal field loss depending on which course of fibres are affected
o Risk factor: small discs
· Optic nerve head drusen
o Accumulation of deposits, calcified mitochondria, in the optic nerve head
o Congenital defect that is typically bilateral
o Visual field defects present in 80% of cases. The defect is usually a relative arcuate defect which is thought to
be the result of the drusen placing pressure on the nerve fibres.

Optic nerve head drusen

· Arcuate scotoma e.g.,
glaucoma
o Damage to a specific bundle of nerve fibres which is reflected in the resultant visual field loss

Optic Chiasm
· At the optic chiasm, approximately 50% of the retinal fibres, including the nasal macula fibres, crosses over to the
contralateral optic tract. Lateral retinal fibres stay in the ipsilateral tract.

· The optic chiasm is closely related to two structures which can impact on the fibres in the chiasm:
o Pituitary gland
 Sits on the sphenoid bone directly below the optic chiasm;
located approximately 10 mm below the optic chiasm.
 80% of the chiasm lies over the back 2/3 of the pituitary
gland
 15% of the chiasm lies in front of the pituitary gland
 5% of the chiasm lies behind the pituitary gland
 Tumours of the pituitary gland can impact the centre of the
chiasm from below.
  Initially, the inferior nasal fibres will be impacted, and with growth of the tumour, all the nasal fibres
will be impacted.

o Circle of Willis
 Major vascular circuit which supplies blood to the brain
 The Circle of Willis surrounds the chiasm
 Haemorrhages and aneurysms at the Circle of Willis, especially the internal carotid artery, can impact
the chiasm. Typically, the lateral aspect of the chiasm is impacted, that is, the temporal retinal fibres.

Optic Tracts
· Further reorganisation of the fibres occurs in the optic tracts as they pass to the lateral geniculate nucleus
o The fibres from the two eyes become more closely associated
o Superior fibres move to the medial aspect and inferior fibres to the temporal aspect
o Macular fibres tend to recognise to the centre
o Lesions to the optic tracts are rare but will typically lead to homonymous defects
o Generally, incongruent but will tend to be more congruent the more posterior the lesion is

Lateral Geniculate Nucleus

· At the lateral geniculate nucleus, the retinal ganglion cells finally synapse with the neurons which pass to the
primary visual cortex
o The parvo- and magnocellular ganglion cells segregate into six separate layers
o The same points in each of the six layers correspond to an identical location in the visual field
· Damage at the lateral geniculate is rare; it is in a well-protected location.
· Fields defects resulting from damage at the LGN tend to be quite congruent
o Damages which are more posterior tend to be more congruent

Optic Radiations
· Damage to the optic radiations is rare
o Damage that occurs is typically vascular in nature e.g., arteriosclerosis
· The extent of the visual field defect will depend on the extent of the neural damage
 o Damages further along the retro chiasmal pathway tend to produce highly congruent visual field defect

· Damage may occur on only the upper or lower fibres of the optic radiation and therefore, causing a lower or upper
quadrantanopia in the opposite half field

Visual Cortex
· The visual cortex is more susceptible to damage as it is located in the occipital
lobe at the posterior brain
· Damage to the area produces highly congruous field defects
· Different visual field defects can result from damage to this area
o Separation of the macular fibres means that the overall field defect may be
macular sparing or macular damaging
· There are three main causes of lesions in the visual cortex:
Vascular – majority of lesions are vascular resulting in a homonymous Hemianopia,
sometimes called hemianopsia, is partial blindness or a loss of sight in half of your
visual field.
o damage such as a hemianopia with or without macular sparing. E.g., stroke of
the posterior cerebral artery.
o Tumours – slow progression and gradual loss is likely.
o Trauma – physical damage can affect one or both hemispheres.

Summary
Pre-Chiasm
· Monocular indicating retinal and/ or Optic Nerve
· Central scotomas – VA and CV are affected
· ON characteristics – defects will point to the disc and respect the horizontal
midline

Chiasm
· Monocular or binocular
· Heteronymous defects (bitemporal or binasal)
· Nasal fibres have the X factor
· Temporal fibres stay therefore, nasal defects indicate same side lesion