VISUAL FIELDS AND VISUAL

FIELD SCREENING

AUTHOR (S)
Luigi Bilotto : Brien Holden Vision Institute, Sydney, Australia
Pirindhavellie Govender : University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER (S)

Bina Patel : New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Visual field – definition

 Perimetry
 Terminology
 Visual pathway, lesions and accompanying visual field defects
 Features used in describing a visual field defect
 Testing the visual field using non-automated instruments and techniques

There are some basic definitions and terms that one should be familiar with before knowing how to conduct a visual
field screening.

VISUAL FIELD – DEFINITION

According to Benjamin (1998) in Borish’s Clinical Refraction, the visual field (VF) is “that area of space that a person
can see at one time”. Even though we function binocularly in most circumstances, the clinical testing of the visual field is
rarely conducted binocularly.
The monocular visual field is 3-dimensional and known as the “Hill of Vision”. The outer edges of which represent the
outermost limits of the area in space, termed the visual field, that can be seen at any one time. Any target, irrespective
of its size or intensity, cannot be seen beyond this area.
The outer or absolute limits of the monocular visual field are: superior: 55-60 degrees, inferior 70 degrees, temporal 100
degrees, & nasal 60 degrees (Fig. 9.1). The shape of the VF is therefore that of a horizontal oval.
 Visual Fields and Visual Field Screening

Figure 9.1 Schematic representation of the extent of the normal visual field of the RE

The nasal limit of the VF in the primary gaze position is limited by the bridge of the nose while superior it may be limited
by anatomical variations including deep-set eyes, ptosis, blepharochalasis or a prominent brow. The practitioner can
verify if the restriction is due to an anatomic restriction by asking the patient to turn their head toward the area of the
suspected anatomic restriction while still maintaining fixation in the straight ahead position. If the restriction was initially
due to an anatomic variation, then the VF will expand outward however, if it does not, then the practitioner may suspect
organic VF defects.
When considering the VF of both eyes in combination, the lateral extend of the VF is about 200 degrees extending from
the right temporal to the left temporal edge. There is an area of overlap between the VF of each eye in the central 120
degrees (nasal edge to nasal edge). This central 120 degrees is referred to as the binocular VF where each eye is able
to detect a stimulus within this region.
The ability to detect a stimulus within the boundaries of the VF depends on the sensitivity which varies with eccentricity,
testing stimulus and the state of retinal adaptation. The Hill of Vision is a three dimensional representation that
represents the sensitivity of eye, with the higher Hill of Vision indicating that there is a greater sensitivity at that location
of the hill. The central part of the eye (i.e. foveal area) contains the highest resolution and is represented by the peak of
the Hill of Vision. The peak sensitivity of the Hill of Vision exists under photopic conditions. Lowering of the lighting
conditions to scotopic conditions depresses the Hill of Vision. It is therefore important for the practitioner to take
cognisance of this since testing should be conducting under photopic conditions. These conditions must remain
constant for successive VF testing in order to make comparisons between successive VF plots.
The blindspot which represents the optic nerve head lays 15.5° temporal to fixation and 1.5° below the horizontal
meridian. The physiological blindspot is 5.5° wide by 7.5° high in diameter. The peripheral parts of the retina display
a decrease in resolution, especially as the distance gets further from the macula.

PERIMETRY

The science of measuring the visual field is referred to as perimetry. There are generally 2 testing strategies to perform
perimetry.

KINETIC PERIMETRY
Kinetic perimetry involves the placement of a selected test stimulus of known size and intensity outside the borders of
the visual field or within the blindspot and then moving it until a point at which it is detected. The boundary at which the
target is first seen have equal sensitivity and if connected, they will form a ring-shaped locus of points referred to as the
isopter. When the size and intensity of the stimulus is changed, another boundary is mapped. These isopters therefore
provide the practitioner with the overall extent of the visual field and gives a measure of the sensitivity of the visual field.

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The isopter may be plotted by target stimuli of various sizes and intensities. This method of visual field measurement
was the traditional approach and remains useful in determining the borders of larger or deeper visual field defects. It is
also generally more useful in peripheral field defects (greater than 30 degree from fixation) and not so useful in central
fields. This has been attributed to the fact that the sensitivity within the central field slopes off at a slow rate resulting in
a zone of greater variability of patient responses. It has also been noted that small isolated reductions in sensitivity
referred to as scotomas are easily missed with kinetic perimetry.

STATIC PERIMETRY
Static perimetry involves the presentation of a stimulus to a specific location on the retina. The intensity of the stimulus
is presented in increasing levels until it is detected by the retina is that specific location. The intensity of the stimulus at
the point of detection is referred to as the threshold. Static perimetry is a good method to detect the sensitivity of the
visual field in a specific area of the retina and is used in Automated perimeters. This method is time consuming and in
newer automated perimeters, strategies are employed to decrease the testing time. Static perimetry is generally much
better at detecting small scotomas such as those that accompany early glaucomatous change.

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TERMINOLOGY

 Units of measurement of a visual field: The visual field is recorded as degrees from fixation.
 Perimetry is the science of measuring the visual field.
 Scotomas refer to an area of reduced or absent visual sensitivity inside an isopter surrounded by an area
of normal or higher sensitivities. It can be classified as:
a) Relative scotoma: is described as an area of depression, in which the target may seem blurry. If a patient has
a relative scotoma, then it is possible that the patient will be able to perceive the target should its intensity and
size be larger.
b) Absolute scotoma: This is an area where the retinal sensitivity in an area that has an absolute scotoma
cannot be increased and therefore even if the practitioner increases the stimulus intensity, the patient will
not be able to perceive it.
c) Unilateral defect: affecting one eye or field
d) Bilateral defect: affecting both eyes or fields

Table 9.1 Comparison of various characteristics between absolute and relative scotomas

Scotoma Type Lesion Margins Scotoma Size

Different size targets will give

Absolute Inactive Steep proportionally the same size
scotomas
Different size targets will give a
Relative Active Sloping different and proportional size
scotoma

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VISUAL PATHWAY, LESIONS AND ACCOMPANYING VISUAL FIELD DEFECTS

A proper understanding of the visual pathway is essential since neurological damage can produce distinctive VF
defects. The shape of the VF defect can assist in identifying the location of the specific disease process that could be
affecting the visual pathway. For example, a bitemporal hemianopsia indicates that the problem is in the optic chiasm
region of the visual pathway.
The visual pathway begins in the retina and terminates in the occipital lobe (Fig. 9.2). Refer to notes in the ocular
anatomy module for a closer review of literature on the visual pathway.

Figure 9.2 A schematic diagram of the visual pathway, its lesions and their accompanying visual field defects

Damage at the level of the retina up to the optic chiasm will result in an ipsilateral defect. A defect that is prechiasmal
may affect both eyes. This occurs at the anterior knee of von Willebrand. Here the nasal fibres that decussate at the
chiasm project forward into the contralateral optic nerve. A lesion in this region results in a junctional scotoma which is
characterised by an ipsilateral complete loss of vision in one eye and a hemianopsia in the other eye.
Chiasmal and post-chiasmal lesions usually cause VF defects that respect the vertical midline. The most common
chiasmal lesion is a bitemporal hemianopia. Post-chiasmal lesions also respect the vertical midline, cause bilateral VF
defects and are typically homonymous hemianopsias. VF defects on the right are associated with problems on the left
hand side of the brain. Lesions along the optic tract also produce bilateral VF defects. Lesions in the temporal lobe
usually result in bilateral homonymous quadranopsias which are typically superior since they affect the inferior fibres
that traverse Meyer’s loop in this region of the brain. These visual field defects are sometimes referred to as “pie in the
sky” defects. The superior fibres pass posteriorly through the parietal lobe and therefore lesions in this area of the visual
pathway tend to produce bilateral homonymous inferior quadranopsias also sometimes referred to as “pie on the floor”.
Eventually fibres pass through to the occipital cortex.

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FEATURES USED IN DESCRIBING A VISUAL FIELD DEFECT

A visual field defect may be described by position, shape, laterality and/or similarity (congruity).

POSITION OF THE VISUAL FIELD DEFECT

When commenting on the position of the visual field defect, one may begin by mentioning that it is either central which
means that the visual field defect will lie within 30° from fixation or it could be peripheral in which case it will lie greater
than 30° from fixation.

SHAPE OF THE VISUAL FIELD DEFECT

The shape can differ when considering its laterality (unilateral or bilateral)

UNILATERAL SHAPES
 The shape of unilateral visual field defects are usually oval or round scotomas. These scotomas are described
by location and shape.
o Central scotomas are defects which involve the fixation point (Fig 9.3 a)
o Centrocoecal scotomas are defects which include the fixation point and the blind spot (Fig 9.3 b)
o Paracentral scotomas are any scotoma within 20°(some say 30°) from fixation but not including fixation
(Fig 9.3 c)
o Pericentral scotomas are defects which surround the fixation point more or less symmetrically (Fig 9.3 d)
o Peripheral scotomas are defects that lie outside the central area
o Bjerrum and Arcuate scotomas are defects that arch over or under fixation into the nasal field. These are
defects that follow the retinal nerve fibre layer. It is a defect that is frequently seen in cases of glaucomatous
damage. Bjerrum’s area extends between 5-20° from fixation (Fig 9.3 e)
o Zonular scotomas are defects which may occupy any part of the visual field with the concavity of the defect
always directed to the fixation point (Fig 9.3 f)
o Altitudinal defects are defects affecting the whole upper or lower field, i.e. above or below the horizontal
midline

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a b c

d e f
Figure 9.3 Schematic diagrams of various types of unilateral field defects
a: central scotoma; b: centrocecal scotoma; c: paracentral scotoma
d: pericentral scotoma; e: Bjerrum’s/arcuate; f: zonular scotoma

BILATERAL SHAPES
 Bilateral visual field defects are often associated with neurological problems. They have a tendency to respect the
vertical meridian.
 Terms used to described bilateral shapes of visual field defects are:
o Hemianopsias are defects that correspond to half of the field (Fig. 9.4 a)
o Quadrantanopsias are defects which correspond to a quarter of the field (Fig. 9.4 b)

Figure 9.4 Schematic diagrams of various types of bilateral field defects

a:hemianopsia; b: quadrantanopsia

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LATERALITY
Laterality of VF defects refers to which side the defects occur, i.e. right or left.

HOMONYMOUS DEFECTS
Homonymous defects are defects that occur on the same side, i.e. either on the right or left hand side of the VF. When
classifying a homonymous defect, the practitioner must make mention if it is a right or left homonymous defect.

HETERONYMOUS DEFECTS
Heteronymous defects are defects affecting opposite sides, i.e. right side of the VF in one eye and the left side in the
other eye. The term heteronymous is sometimes replaced by stating whether a VF defect is either binasal or bitemporal.

Figure 9.5 Schematic diagrams visual field defects described by laterality

(a) homonymous defect; (b) heteronymous defect

CONGRUITY
Congruity of a VF defect is considered when a VF defect is bilateral.

NON-CONGRUOUS (INCONGRUOUS) DEFECTS

Non-congruous defects are those visual field defects that are not similar to each other (Fig. 9.6a).

CONGRUOUS DEFECTS
Congruous defects are those visual field defects similar to each other between the 2 eyes. Congruous VF defects are
often found in the more posterior aspects of the visual pathway (Fig. 9.6b).

Figure 9.6 Schematic diagrams visual field defects described by congruity

a: Incongruous defect; b: Congruous defect

After screening or testing the VF, one must be able to compare the findings to those that one would expect with defects
along the visual pathway.

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TESTING THE VISUAL FIELD USING NON-AUTOMATED INSTRUMENTS

AND TECHNIQUES

1. CONFRONTATIONAL VISUAL FIELDS

Introduction
 Confrontational fields allows the detect of moderate size visual field defects

Indications
 A screening test that is an essential part of the routine comprehensive eye examination
 It is performed when one requires a general field screening
 It is especially useful in patients whom automated perimetry is impossible to perform, for example, bedridden
patients, children

Advantages
 It is a simple test to perform
 It is quick
 It does not require any special instrumentation

Disadvantages
 It is able to only detect gross defects
 It may not be used for monitoring purposes
 It allows too much inter-examiner variability in terms of deviation of methodologies, stimuli sizes and speed
of presentation of stimuli

METHOD 1: CONFRONTATION FIELD SCREENING METHOD

Technique
1. Facial Amsler (FA)
2. Central Finger Counting (FC)
3. Simultaneous Finger Counting (SFC)
4. Hand comparison (HC)
5. Peripheral Finger Counting (PFC)

Preparation
1. An overhead lamp is placed above the patient’s head and directed toward the practitioner.
2. The practitioner sits directly across from the patient, at eye level, so that your face is about 60cm from the
patient (Fig. 9.7).
3. The patient is instructed to occlude one eye (LE first) with the palm of the left hand.
4. Patient fixation is directed at the practitioner’s nose.
5. The practitioner must ensure that they observe the patient’s fixation throughout the test procedure.
6. The practitioner’s hands are placed halfway between himself and the patient for each of the following
procedures.
7. The targets presented are the practitioner’s fingers in 0 (no fingers shown), 1, 2, 5 finger combinations.
Others combinations are avoided as they may cause confusion for the patient.
8. No prescription is necessary. If the patient does have a high refractive error, then the prescription is used for
the central visual field assessment and removed for the peripheral visual field assessment. This is done since
the spectacle frame would prevent the patient from detecting the presence of the target in the peripheral
positions due to it physically obstructing the peripheral targets.

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Figure 9.7 Position of practitioner and patient facing each other at eye level during screening
of visual fields using the confrontation test

1. Facial Amsler (FA)

 Occlude the patient’s non-tested eye
 The patient is asked: “Can you see my nose? And “While looking at my nose, is there anything missing or blurry or
dimmer on my face? Can you see my eyes, ears, chin, top of my head and eyebrows?”
 This test checks for central scotomas and scotomas in the central field
 The distance you are sit from the patient will alter the location of findings

2. Central Finger Counting (FC)

 The target (hand position as in Fig. 9.8) is presented to the patient in each of the 4 quadrants separately (Fig. 9.9)
 The patient is asked: “How many fingers do you see?” Start with a close fist
 This step detects the presence of absolute scotomas in each of the 4 quadrants. One quadrant is tested at a time
 Throughout the procedure, the practitioner must ensure that the patient is fixating the practitioner’s nose or eye

Figure 9.8 Hand position in finger counting examination of confrontation field test

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Figure 9.9 Presentation of fingers in the upper left quadrant of the visual field before patient

3. Simultaneous Finger Counting (SFC)

 Two targets (hands as in Fig. 9.10) are presented targets simultaneously, first in each of the 2 upper quadrants
(superior temporal and superior nasal fields) and then in the 2 lower quadrants (Fig. 9.11)
 The practitioner must ensure that the patient remains fixating the practitioner’s nose throughout the procedure
 The patient is asked: “How many fingers in total do you see?”
 This step detects the extinction phenomenon which may be present in parietal lobe lesions

Figure 9.10 Hand position in simultaneous finger counting examination of confrontation field test

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Figure 9.11 Presentation of fingers in upper quadrants of the visual field

4. Simultaneous Hand Comparison (SHC)

 Simultaneous hand comparison detects relative defects
 It must be noted that neurological defects respect the vertical midline

This procedure is made up of 2 parts:

a) The practitioner presents his hands with palms facing himself, side by side on either side of the vertical,
an imaginary line (Fig. 9.12).
- The patient is asked: “As you look at my nose, is one hand clearer or brighter than the other
or are they about equal?”
- The practitioner must be careful of shadows produced by light that is unequally distributed
or misdirected in the testing environment
- This step checks for a relative hemianopsia

Figure 9.12 Presentation of hands during simultaneous

hand comparison for the detection of relative hemianopsias

b) The practitioner presents his hands one above the other on either side of the horizontal, the fingers of each
hand pointing towards each other. Position them first nasally, then temporally (Fig. 9.13).
- The patient must remain fixating the practitioner’s nose throughout the procedure
- The patient is asked the same questions as for step a, i.e. “As you look at my nose, is one hand clearer
or brighter than the other or are they about equal?”
- This step detects the presence of relative quadranopsias, altitudinal hemianopias and nasal steps

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Figure 9.13 Presentation of hands during simultaneous hand comparison for the detection
of relative quadranopsias, altitudinal hemianopias and nasal steps

5. Peripheral Finger Counting (PFC)

 This procedure detects finger counting in the periphery of each of the 4 quadrants
 Fingers are shown as far out as possible in a place halfway between the examiner and the patient, just inside
the boundary of the examiner’s own field in the examiner’s corresponding eye (Fig. 9.14). (One assumes that the
examiner’s visual field is normal)
 E.g. testing the patient’s RE, the target is presented just inside the boundary of the field of the examiner’s LE
 This allows a comparison of the examiner’s field with the patient’s field since the 2 fields correspond
 An alternative technique for this step is the kinetic confrontation visual field examination which also determines
the extremities of the patient’s visual field

Figure 9.14 Presentation of fingers in peripheral finger counting

Recording the findings
The visual field results are recorded as follows:
For a normal visual field:
OD: full (with facial amsler testing method) or comparable to examiner (with kinetic field screening)

For a visual field with a restriction:

OD: restricted in superior temporal quadrant
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METHOD 2: KINETIC CONFRONTATION VISUAL FIELD EXAMINATION

This test not only allows one to determine the boundaries or extremities of the visual field, but is also capable
to detecting defects within the boundaries.

Instrumentation
 Overhead lamp (not always necessary)
 Target (transilluminator, knitting needle, white sphere suspended on a non-glossy black wand)
 Some texts prescribe a spherical target of 4mm diameter on a thin stick.

Procedure
1. Have the patient remove his/her spectacles. The rims of the spectacles may obstruct the view of the target
and should therefore be eliminated.
2. The practitioner and the patient face each other and must be at eye level at about an arm’s length away
(approximately 60cm).
3. The test is performed monocularly.
4. Instruct the patient form a cup with his left hand and place it over his left eye, while you form a cup with your
right hand and place it over your right eye. Ensure that the patient is using the palm of his hand and not the
fingers, as he may look through them.
5. While the patient is instructed to keep looking into your open right eye, bring in the target from an unseen
position to a point at which the patient is able to “notice” the target in their field of vision gradually. This target
must be held midway between yourself and the patient (Fig. 9.15). The patient needs to be made aware
of the fact that they will not “see” the target clearly but rather that they will be aware of its presence in the
field of vision.
6. The target is moved in towards the patient in the different visual field quadrants.
7. One should not stop moving the target once the patient reports that he first notices the target in his field
of vision. Thereafter the target is moved across the central area of the field to determine if there are any
central visual field losses. The Px must be asked to report if the target disappears or fades at any point.
8. The procedure of moving the target from unseen to seen and then within the central area of the visual field
must be conducted along the 8 radial meridians. At all times, the examiner must watch that the Px does
not lose fixation. If this happens, then the procedure must be repeated along that meridian.
9. One may also be able to plot the dimensions of the blindspot.
10. Once you have mapped out the visual field of the right eye, repeat the procedure for the left eye.

This test compares the Px’s visual field with that of the examiners. It is conducted under the assumption that
the examiner has a normal visual field. (Remember to check yours!!)

Figure 9.15 Position of the target midway between the practitioner and patient
when conducting the kinetic confrontation field test

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Findings
If one detects a visual field restriction, one needs to record in which direction the field defect lies. By mapping these
defects, one may hazard a guess as to where the problem lies within the visual pathway. It should be mandatory for the
examiner to request a comprehensive visual field examination should there be any inconsistencies with the results of
the confrontation field test. Defects within the extremities of the visual field may sometimes are usually significant
enough before this gross screening test is able to detect them.
One should note that in cases of suspected glaucoma, especially in the early stages, the visual field changes are more
subtle. Even if the confrontation test yields no gross visual field defects, further visual field testing should be
recommended to the patient given the ocular disease history.
NOTE: Retinal defects are in the opposite direction to the visual field defect, i.e. a superior visual field defect implies an
inferior retinal defect.

Recording
 Record all defects and their approximate locations (Fig. 9.16). e.g. for left homonymous superior quadranopsia

Figure 9.16 Recording of visual field defects

2. TANGENT SCREEN
 This is a kinetic investigation of the visual field and is a common perimetric method available. It is more sensitive
than confrontation or finger counting fields
 It is able to provide an accurate charting of central and paracentral visual field defects
 Useful in testing patients with hysterical fields
 However, tanget screen is not considered standard of care in managing glaucoma

Instrumentation
 The tangent screen is a screen made of a black felt background with semi-visible black circular stitching every
5° (Fig. 9.17). It usually also has radial stitching that starts at the 180 meridian running through the fixation point
every 22.5 degrees (however, this can vary from chart to chart)
 It tests the central field, 30º of visual field
 It uses a test distance of 1 meter
 It is useful in detecting the size and location of larger scotomas. It allows the examiner to vary the target size

Figure 9.17 The tangent screen

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Procedure
1. Testing distance is typically 1m.
2. Monocular test. Patch the non-tested eye.
3. Patient is directed to view a central fixation dot.
4. The patient should be wearing their prescription if over -1.75DS or +1.00DS. If they are presbyopic they should
have a +1.00 D lens placed in a trial frame over their distant correction, assuming the tangent screen is at one
meter. Patients should never wear glasses with multifocal lenses when being tested as it causes too many
distortions and the chart will not be clearly visible in the straight ahead position.
5. The practitioner begins exploring the visual field by presenting targets beginning with a 3mm white target unless
visual acuity reduction necessitates the use of larger target.
6. If the patient cannot see the central dot due to the presence of a central scotoma, 2 lines of white tape that
cross at the fixation dot (form an “X”)may be used. The patient should be directed to fixate “straight ahead”
where he thinks the 2 lines cross, even if that region is obscured or distorted.
7. All plotting is done from non-seeing to seeing. It is a good idea to plot the patient’s blind spot first so the patient
understands everyone has an area of non-seeing which is normal, plus, they will have a better understanding
of what it is like when the target disappears.
a) Testing the visual field: Determine the threshold at 25° temporally. Take a 1mm white target and ask
patient if they see it. Hold it statically at 25°. Increase the size of the target incrementally till the patient
sees the target.
b) This will be the threshold target. Plot 4 points on the temporal field (just above and below the horizontal
meridian).
c) Proceed to plot the blind spot. Plot 8 points to outline the blind spot from non-seeing to seeing. Once
plotted take target around the blind spot circumference to verify border.
d) Plot temporal field at 15° intervals. Scan along the inside of the temporal field to ensure no scotomas are
in this area.
e) Repeat 7d. but on the nasal aspect.
8. One must be careful when interpreting findings. There are some conditions that may cause field defects that
resemble glaucoma defects.(i.e., cataracts and drusen of the optic nerve heads) may result in an arcuate fibre
scotomas. Enlargement of the blind spot is not diagnostic of glaucoma.
9. The practitioner should always plot from non-seeing to seeing from the periphery starting on only one side
of the tangent screen.
10. The practitioner should never lean across to plot the opposite side, but rather walk around the back of the
patient to the other side and repeat the same procedure. He should make sure as he plots the hemi-field
that he runs the target through the blind spot to insure the patient is paying attention.
11. As a check for patient attention, the practitioner can also turn the target over so the patient can no longer see
it, checking to see if the patient is paying attention. About 90% of the time the practitioner must be watching
the patient ensuring they are indeed looking at the fixation point and not at the target.
12. The tangent screen targets are pigments. Therefore, the test is more sensitive the dimmer the lighting is on
the screen (more difficult to see). The light falling on the tangent screen should be 7 foot candles. This is not
that important when using white targets as it is with colored targets. Therefore, if the practitioner does not have
good control over the lighting in an examination room the test can be run with subdued lighting and not the
recommended 7 foot candles.
13. With coloured targets the lighting is very important and one must try and have the illumination as to near to
7 foot candles as possible. The nasal field represents the temporal retina and the temporal field represents
the nasal retina.
14. If the practitioner wishes to extend the range of the visual field being tested using the Tangent Screen, he can
increase the testing distance of the patient from the chart, but must take note that the position of the blind spot
indicated on the chart will not be in the same position. If the practitioner doubles the testing distance then he will
also double the size of the blind spot and any other scotomas detected.
15. The doubling of the testing distance is sometimes used as a method of detecting malingering in a patient. Plot
field using a 3mm white target at 1m. Then re-plot using at 2 m with a white target. If the linear size for both field
plots is the same, it indicates a hysterical field. Alternatively, the test distance can be kept the same and modify
only the test target: e.g. a 6mm white target at one meter should give a bigger field then a 3 mm target.

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Recording
 The recording of findings of the actual points detected with the stimulus are plotted on the Tangent screen recording
sheet (Fig. 9.18).

Figure 9.18 Tangent screen recording form

 In addition to a diagrammatic representation must include :

a) Test Target Size (mm) written over Testing Distance (mm), e.g. "1 mm W" /"1000 mm"
b) Target Color. e.g. White (W)
c) Patient cooperation
d) Visual Rx and acuity

Example of a tangent screen plot (Fig. 9.19).

Patient X:
OD: + 1.00DS (6/6) OS: + 1.00DS (6/5) OU: 6/5

The test was conducted with a 1mm size white target at a distance of 1meter.

Figure 9.19 Example of tangent screen plot

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3. AMSLER GRID
The Amsler grids kit is a set of 7 charts (10 X 10 cm) used to detect small abnormalities (~1°) in the central VF that
could remain undetected by the usual methods of VF testing. At the appropriate testing distance, the charts are
specifically designed to assess a central 20° field. Anatomically, this correlates with the area just inside the temporal
vascular arcades but excluding the optic nerve (Fig. 9.20).
Each chart has a different pattern and is recommended for different purposes. In general, however, the charts serve to
detect small central scotoma or metamorphopsia. Metamorphopsia is an anomaly of visual perception in which objects
appear distorted, larger (macropsia) or smaller (micropsia). This is generally due to pathological changes in the fundus
that result in a displacement of photoreceptors. Metamorphopsia may, however, also have a central origin
(e.g. migraine).

Figure 9.20 Amsler grid representation on the retina

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Instrumentation

Chart #1
The first Amsler chart is the standard grid which is the most familiar and widely used.
It is a 20X20 white square grid on a black background with a white central fixation dot.
Each square (5mm) corresponds to 1° of VF at the standard testing distance of 30cm.
The chart is used to reveal distortion, relative and absolute scotomas.

Chart #2
The second chart is similar to the first except that 2 diagonal lines intersect at the
center of the grid. These are used for patient with a central scotoma that cannot
fixate the central dot. The lines will orient the patient’s fixation by allowing fixation
approximately where the lines would cross.

Chart #3
The third chart is similar to the first but the squares are red instead of white. The chart
is particularly useful for patients with suspected central or cecocentral scotomas that
are commonly due to toxic (e.g. alcohol, chloroquine, etc.) or nutritional amblyopia.
It may also used as a deceptive test to detect malingering (faking, false vision loss)
when used with red-green lenses. In normal condition, the red grid will disappear
when viewed through a green lens but will remain when viewed through a red lens.
Malingerers will claim that the lines are invisible in both the red and green filters.

Chart #4
The fourth chart is composed of small white dots (no lines) on a black background.
The chart is indicated for patients with one or more paracentral scotoma making
it easier to delineate the affected areas.

Chart #5
The fifth chart consists of 20 white horizontal lines evenly spaced by 5mm on a black
background. The chart may be rotated for evaluation in any meridian to facilitate the
identification of “oriented” metamorphopsia which primarily affects lines going in
one direction.

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Chart #6
The sixth chart is similar to the 5th except that it is made of black lines on a white
background. It also contains 2 additional lines in the 1° region above and below the
fixation dot. This chart is meant to facilitate the observation of metamorphopsia
along the reading level.

Chart #7
The last chart is similar to chart # 1 but the inner 6° X 8° which corresponds
anatomically to the macular area includes smaller 0.5° white squares instead of 1°.
The smaller grid is intended to facilitate the detection of subtle visual disturbances
in the macular area.

Procedure
The Amsler grids are performed under uniform bright illumination (F+) at a testing distance of 30 cm. The patient must
be undilated with the best near Rx in place. The test is performed preferably before any contact or fundus observation
procedure to insure that the result is unaffected by previous tests. Amsler grids are always tested monocularly with the
better eye tested first to facilitate the patient’s understanding and observations. Fixation must constantly be
monitored. The test is performed asking the following 5 questions to the patient:

1. Can you see the central white dot?

This question rules out relative or absolute central scotomas. If no central dot is visible then an absolute scotoma
is present and chart #2 should be used. If the central dot appears faint or blurry, a relative scotoma may be present.

2. Continue looking at the central white dot. Can you see all 4 sides & corners of the large square?

This rules out arcuate, altitudinal, quadrantic, hemianopic or field constriction defects. If the answer is “no”, the patient is
asked to document the defect. Chart #3 may be used to facilitate the observation of a suspected cecocentral scotoma.

3. Continue looking at the central white dot. Are any of the small squares blurry or missing on any part of the
grid?

This step rules out relative or absolute paracentral, cecocentral, or altitudinal scotomas. If the answer is “yes” first rule
out bad refractive correction or media opacities. If squares are definitely missing or blurry then an absolute or relative
scotoma may exist and the patient is asked to document the defect. To make defect clearer chart #4 may be presented.

4. Continue looking at the central white dot. Do any of the horizontal or vertical lines that make up the square
appear wavy or bent?

Metamorphopsia is addressed here. If the answer is “yes”, first rule out artifacts resulting from multifocal lenses. Then
ask the patient to document the defect. Waviness can range from minimum to severe with some of the lines being
discontinuous or broken.

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Macropsia, which results from increased photoreceptors density, will make a square appear
rounded like a barrel.

Micropsia, the opposite, will make the square appear like a pinecushion.

5. Continue looking at the central white dot. Is any part of the grid shimmering, flickering, or colored?

This helps rule out scintillating scotomas which are commonly associated to migraines but which can also result from
retinal causes (e.g. serous detachment) or visual pathway lesions (e.g. AV malformation).

Modified Procedures
Threshold Amsler grids: A modified testing procedure can help increase the sensitivity of Amsler grids to detect very
shallow (subtle) VF defects. Two cross-polarized filters are placed in front of the eyes and rotated with respect to each
other to reduce the contrast of the grid against the black background until it is barely discernible. This sets up a
threshold situation that facilitates the recognition of VF alterations. Relative scotomas are easier to detect and absolute
scotomas easier to observe. The procedure is the same as described above.
Modified Amsler grids: Several modified Amsler charts are available on the market. Despite some additional features
that may present some advantages, their principle remains similar to the conventional Amsler grids.

The Yanuzzi card is a minified version of Amsler chart # 7 the

size of a credit card (16° X 10°). The advantage of the Yanuzzi
card lies in its ease of portability.

The Transilluminated grid is similar to the standard Amsler grid except that it is constructed by punching 1mm holes
(5mm apart) in a steel card to form the grid pattern. The transilluminated chart is advantageous in patients with media
opacities that cannot view the standard chart.

The Diamond chart is similar to Amsler chart #5 except that it

has black lines on a white background. The advantage of the
Diamond chart lies in that it contains a 5mm central red fixation
dot and a red diamond 10cm to one side of the dot that allows for
proper distance control. When held at the proper working
distance (40cm for Diamond grid), the diamond falls into the
blind spot and disappears. The diamond also ensures monocular
viewing: should the test accidentally be performed binocularly,
the diamond will not disappear.

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ADDITIONAL INFORMATION
Amsler grids are frequently dispensed for patients to perform self-monitoring at home. These are useful to monitor
progressive, recurrent, active or inactive diseases that affect the central area and threaten vision. Amsler grids are
particularly useful for age-related macular degeneration which affects a significant segment of the older population.
The self-assessment Amsler grids are prescribed for the interval between eye examination. Depending on the severity
of the condition, the frequency of self-testing can range from once a day to once a week. The self-monitoring Amsler
grid should be placed in an area where patients will be reminded to perform the procedure (e.g. on the refrigerator, toilet
mirror etc.) The instructions described above are given both verbally and in writing and the patient is advised to call the
office and return for consultation immediately should any visual change be noticed.

Recording
If scotomas are noted, the patient is asked to describe, show and draw the location & delimitation on the chart. Patient’s
remarks about the appearance and depth of the scotoma are added. Comments about the result’s reliability based on
the patient’s characteristics and expressions are noted as well. The grid is identified, dated and appended to the
patient’s record.

Lines distorted scotoma

BIBLIOGRAPHY
Benjamin WJ. Clinical Refraction. WB Saunders Company. 1998.
Elliot DB. Clinical Procedures in Primary Eye Care. Butterworth-Heinemann 2001.
Eskridge JB, Amos JF and Bartlett JD. Clinical Procedures in Optometry. JB Lippincott Company. 1991.

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