VISUAL FIELD TESTING - A REVIEW

(A.V.Chandrinos – 2008)

INTRODUCTION

1. DEFINITION OF VISUAL FIELD

1.1. THE NORMAL VISUAL FIELD
1.2. MANUAL PERIMETRY: THE GOLDMANN VISUAL
FIELD
1.3. KINETIC PERIMETRY
1.4. STATIC PERIMETRY
1.4.1. Static suprathreshold and threshold testing.

1.5. AUTOMATED PERIMETRY

1.6. BLEU ON YELLOW PERIMETRY

2. LIGHT AND VISUAL FIELD

2.1. THE DIFFERENTIAL LIGHT THRESHOLD
2.2. SENSITIVITY VERSUS THRESHOLD
2.3. APOSTILBS AND DECIBELS

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3.VISUAL FIELDS AND GLAUCOMA
3.1. GLAUCOMATOUS VISUAL FIELD DEFECTS
3.2. DIFFUSE DEPRESSION
3.3. LOCALIZED NERVE FIBER BUNDLE DEFECTS

3.3.1. NERVE FIBER BUNDLE DEFECT

3.3.2. PARACENTRAL DEFECTS
3.3.3. ARCUATE SCOTOMAS
3.3.4. NASAL STEP DEFECTS
3.3.5. TEMPORAL WEDGE-SHAPED DEFECTS

3.4. EARLY VISUAL FIELD DEFECTS

3.5. BLIND SPOT CHANGES
3.6. COMMONLY USED PROGRAMS FOR GLAUCOMA.
4. TESTING PARAMETERS
4.1. ASSESSING RELIABILITY
4.2. GLOBAL INDICES
4.3. INTER EYE COMPARISONS
5. TESTING THE PATIENT
5.1. VISUAL FIELD TESTING (PERIMETRY)
5.2. CONCLUSIONS ABOUT VISUAL FIELD TESTING ROUTING

References

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INTRODUCTION

During a routine eye exam, some eye doctors may want to

determine through visual field testing the full horizontal and vertical
range of what you are able to see peripherally. This is commonly
referred to as "side vision."

Visual field tests assess the potential presence of blind spots

(scotomas), which could indicate eye diseases. A blind spot in the
field of vision can be associated to a variety of specific eye diseases,
depending on the size and shape of the scotoma.

Many eye and brain disorders can cause visual field

abnormalities. For example, optic nerve damage caused by
glaucoma creates a very specific visual field defect. Other vision
problems associated with blind spots developing within the visual
field include optic nerve damage (optic neuropathy) from disease or
toxic exposure or damage to the light-sensitive inner lining of the
eye.

Nevertheless, brain abnormalities such as those caused by

strokes or tumours can affect the visual field. In fact, the location of
the stroke or tumour in the brain can frequently be determined by
the size, shape and site of the visual field defect.

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1. DEFINITION OF VISUAL FIELD

1.1 THE NORMAL VISUAL FIELD

The field of vision is defined as the area that is perceived, at

the same time, by a fixating eye. The limits of the normal field of
vision into the superior field are 60°, into the inferior field 75°,
temporally 110°, and nasally 60°.
Visual field in his classic term has been described as “an island
of vision in the sea of darkness”. The island represents the perceived
field of vision, and the sea of darkness is the surrounding area that is
not seen. In the light-adapted state, the island of vision has a steep
central peak that corresponds to the fovea, the area of greatest
retinal sensitivity.
The contour of the island of vision relates to both the anatomy
of the visual system and the level of retinal adaptation. The highest
concentration of cones is in the fovea, and most of these cones
project to their own ganglion cell. This one-to-one ratio between
foveal cone and ganglion cell results in maximal resolution in the
fovea.

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1.2. MANUAL PERIMETRY: THE GOLDMANN VISUAL FIELD

The Goldmann perimeter is a widely used instrument for

manual perimetry. It is a calibrated bowl projection instrument with a
background intensity of 3 1.5 apostilbs (asb), which is well within the
photopic range. The size and intensity of targets can be varied to plot
different isopters kinetically and determine local static thresholds.
A Roman numeral, a number and a letter identify the stimuli
used to plot an isopter. The Roman numeral represents the size of
the object, from Goldmann size 0 (1/16 mm2) to Goldmann size V (64
mm2).
Each size increment equals a double increase in diameter and a
quadruple increase in area. The number and the letter represent the
intensity of the stimulus. A change of one number represents a 5-db
(0.5 log unit) change in intensity, and each letter represents a 1-db
(0.1 log unit) change in intensity. The dynamic range of the
Goldmann perimeter from the smallest/dimmest target (01a) to the
largest/brightest target (V4e) is greater than 4 log units, or a 10,000-
fold change.

Isopters in which the sum of the Roman numeral (size) and

number (intensity) are equal can be considered equivalent. For
example, the I4e isopter is roughly equivalent to the II3e isopter. A

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change of one number of intensity is roughly equivalent to a change
of one Roman numeral of size.
Usually the equivalent isopter combination with the smallest
target size is preferred, because detection of isopter edges is more
accurate with smaller targets. One usually starts by plotting small
targets with dim intensity (I1e) and then increasing the intensity of
the target until it is maximal before increasing the size of the target.
The usual progression then is I1e (ARW1) I2e (ARW1) I3e (ARW1)
I4e (ARW1) II4e (ARW1) III4e (ARW1) IV4e (ARW1) V4e.

1.3. KINETIC PERIMETRY

In kinetic perimetry, usually a stimulus is moved from a non-

seeing area of the visual field to a seeing area along a specific
meridian. The procedure is repeated with the use of the same
stimulus along other meridians, usually spaced every 15°.
Using kinetic perimetry, the clinician attempts to find locations
in the visual field of equal retinal sensitivity. By joining these areas of
equal sensitivity, an “isopter” is defined.
The size and the luminance of the target are changed to plot
other isopters. Therefore, the island of vision is approached
horizontally. Isopters can be considered the outline of horizontal
slices of the island of vision.

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1.4. STATIC PERIMETRY

In static perimetry, the size and location of the test target

remain fixed. At the specific location retinal sensitivity is determined
by varying the brightness of the test target. The shape of the island
is defined by repeating the threshold measurement at various
locations in the vision field.

1.4.1. Static suprathreshold and threshold testing.

In addition to plotting isopters kinetically, static suprathreshold

and threshold testing can be performed manually. Once an isopter is
plotted, the stimulus used to plot the isopter is used to statistically
test within the isopter to look for localized defects. In this way, it acts
as a suprathreshold stimulus. Static thresholds also can be
determined along set meridians to obtain profile plots of the visual
field, but like any multiple thresholding task, it is time consuming.

1.5. AUTOMATED PERIMETRY

Perimetry is a fundamental clinical investigative procedure as it

can provide information concerning the localization and type of lesion
affecting the visual pathway. The technique can be used purely for

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the detection of a field defect or can be further used to assess both
the depth and area of loss and rate of progression of the loss with
treatment. Further more, it provides valuable information concerning
the assessment of visual disability.

The basic principle of perimetry is the measurement of the

differential light threshold, namely the minimum stimulus luminance,
AL necessary to evoke a response against a background, L of a given
constant luminance. The response of the visual system is
conventionally represented in terms of sensitivity, which decreases
from foveal fixation with increase in peripheral angle and has been
linked to a hill, or island of vision.

Computers evolution and automation introduced a new era in

perimetry testing. Static testing can be performed in an objective and
standardized pattern with minimal perimetry bias. A quantitative
representation of the visual field can be obtained more rapidly than
with manual testing. The computer allows stimuli to be presented in
a pseudorandom, unpredictable appearance. Patients do not know
where the next stimulus will appear, so fixation is improved, by
increasing the reliability of the test. Random presentations also
increase the speed with which perimetry can be performed by
bypassing the problem of local retinal adaptation, which requires a 2-
second interval between stimuli if adjacent locations are tested.

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 Traditionally, perimetry has employed the kinetic technique and
the Goldmann Bowl Perimeter has been the definitive instrument for
many years. In the 1970s, single and also multiple stimulus static
perimetry became accepted as a more superior technique for the
investigation of glaucoma.

Single stimulus presentation was used with the Goldmann

perimeter and to a lesser extent with the Tubinger, while multiple
presentations was employed in instruments such as the Friedmann
Visual Field Analyzer which became a standard in its own right.
Following the development of automated perimetry in the late 1970s
potential of the visual field examination used in clinical diagnosis.
Indeed, in recent years, computer-assisted static perimetry has
become the method of choice for the examination of glaucoma.

Computer-assisted perimetry can be defined as a form of visual

field examination in which part or all of the examination is performed
by a microcomputer or microprocessor instead of by a human
examiner. More specifically, the term automated perimetry is used
when the decision-making process of the examination strategy is
exclusively controlled by computer (Greve, 1983) and does not
require any operator interaction; the perimetrist merely attends to
the positioning of the patient and to the monitoring of patient-specific
variables such as understanding, anxiety or fatigue.

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 The consequence of automated perimetry springs largely from
the fact that in terms of equivalent data obtained by comparable
manual techniques, the rapidity of the examination produces less
patient fatigue and facilitates viable and more extensive visual field
investigation; nevertheless, a clinician or skilled perimetrist is
necessary only for the interpretation of the recorded data. In
addition, the stimulus parameters are standardized; the examination
strategy is exactly definable and reproducible, and the software
permits extensive data storage and retrieval and pretentious
statistical analysis. Furthermore, the technique can be customized to
suit the requirements of the user. However, the overriding advantage
of the technique, is that when used appropriately it is at least, if not
more, accurate than conventional manual perimetry. The practice of
perimetry is currently in a transition period between manual and fully
automated procedures.
Nevertheless, the theory of automated perimetry is still in a
state of advancement and the commercially available instrumentation
can appear to incorporate a bewildering array of stimulus parameter
options, together with a complexity of operating procedures
controlled by the software. Indeed, many of the stimulus parameters
and investigation procedures have been incorporated into the
modern instrumentation on a largely empirical basis and frequently
are derived from the design of the earlier manual kinetic
instrumentation. In contrast, other automated perimeters have a firm
scientific basis to their design and offer greater clinical potential.

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 1.6. BLUE ON YELLOW PERIMETRY

Many years ago, colour perimetry has been a topic of research.

Isolation of short-wavelength-sensitive mechanisms, using visual field
testing procedures, was pioneered by the work of Marre (1972),
Zisman et al. (1978), King-Smith et al. (1984), Kitahara et al. (1982),
Hart et al. (1984) and Hart & Gordon (1984).

However, it was not until the two-colour increment threshold

technique was applied to automated perimetry that such procedures
became a feasible clinical diagnostic tool. The two-colour increment
threshold method of Stiles states that the individual colour
components can be isolated or unfolded by selectively reducing the
sensitivity (or influence) of competing mechanism (Stiles 1959).

Blue-on-yellow perimetry is designed to test the SWS channel

selectively. The SWS channel has its maximum sensitivity at 440 nm
(blue). The medium-wavelength-sensitive (MWS) and long-
wavelength-sensitive (LWS) channels, however, have the same
sensitivity at this wavelength as the SWS channel with no
background. In order to test the SWS channel selectively it is
necessary to decrease the sensitivity of MWS and LWS channels,
relative to the sensitivity of the SWS channel. A yellow background
that contains only wavelengths above the 550 nm achieves this.

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 Although maximum separation between the sensitivity of the
SWS channel and the MWS and LWS channels is reached if the
brightness is 200 cd/m2 the difference with the background at 100
cd/m2 is not significant. A background luminance of 100 cd/m2 is
recommended because it provides a better dynamic range, is more
comfortable for the patients and does not require fans to cool the
system.

A significant factor that restricts the use of B/Y perimetry as a

clinical diagnostic procedure is the yellowing of the lens with
increasing age. Previous studies have reported that there is a
selective absorption of short-wavelength light by the ocular media,
thereby decreasing the amount of short-wavelength light that is
transmitted to the retina. The reduced transmission causes a
reduction in the height of the hill of vision. Therefore, to distinguish
short-wavelength sensitivity deficits that are related to optic nerve
damage from transmission losses occurring at the lens, it is
necessary to measure the wavelength-dependent transmission
properties of the lens. In previous studies of B/Y perimetry the
absorption by ocular media was measured using the technique of
Sample et al. (1989). This involved the measurement of two scotopic
thresholds of equal sensitivity to rhodopsin (i.e., 410 nm and 560
nm) at approximately 15° eccentricity in each quadrant. The
differences in scotopic sensitivity were attributed to wavelength-
dependent absorption by the ocular media.

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 However, measuring the lens density index using this method is
not practical in many clinical settings, because it necessitates time-
consuming dark adaptation and requires about 40 minutes to
complete. Moreover, it is not clear how this method works in patients
with damaged retina. A video based method using a double-pass
Purkinje image reflection technique and a technique using the retina
as reflector for a double-pass measurement of lens density (Delori &
Burns 1996) have also been reported but for some reason not used
on B/Y perimetry procedure so far.

The optical media problem has also been tried to solve by

applying statistical analyses to the field in order to factor out lens
effects (Sample et al. 1994, Wild et al. 1995). Examination of
asymmetry in manner similar to the glaucoma hemi-field test helps
identify only localized B/Y perimetry deficits. According to Sample &
Weinreb and Hart et al. (1990) studies, the short wavelength-
sensitivity losses related to glaucomatous damage appear, however,
to have both a generalized and a localized component.

Many studies have shown that there is both an increase in

short-wavelength transmission loss and greater variability from one
individual to another, in persons older than 60 years. Johnson et al.
(1988) and Wild et al. (1995) found that correction for ocular media

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absorption did not reduce the between-subject variability of the B/Y
mean sensitivity.

Wild et al. (1995) suggested that any individual difference from

the height of the average age-matched normal uncorrected field,
because of ocular media absorption, could be removed using the
pattern deviation approach. Such an approach ignores any diffuse
component from optical factors but as well from neural damage. In
view of the fact that a diffuse loss of nerve fibers is the most
common pattern in early glaucoma it seems reasonable to suggest
that the diffuse component of functional loss is not uncommon, and
therefore the correction of B/Y perimetry results also for the lens
transmission losses is warranted.

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 2. LIGHT AND VISUAL FIELD

2.1. THE DIFFERENTIAL LIGHT THRESHOLD

Static computerized perimetry measures retinal sensitivity

at predetermined locations in the visual field. These perimeters
measure the ability of the eye to detect a difference in contrast
between a test target and the background luminance. The differential
light threshold is defined as the dimmest target seen 50% of the
time. Suprathreshold stimuli are brighter than threshold stimuli, and
they will be seen more than 50% of the time. Infrathreshold stimuli
are dimmer than threshold stimuli, and they will be seen less than
50% of the time.

Threshold at a specific retinal location can be measured directly

from a frequency-of-seeing curve. Testing one retinal location
multiple times with different stimulus intensities the frequency-of-
seeing curve is generated. The frequency-of-seeing curve is the
graph of the percentage of stimuli seen at each intensity level.
Threshold is read off the graph at the 50th percent line.

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 Frequency of seeing curve

Stimuli of varying intensities are presented multiple times at

one retinal location. Threshold is defined as the dimmest stimulus
seen 50% of the time.

2.2. SENSITIVITY VERSUS THRESHOLD

As one measures the vision toward the fovea, the sensitivity of

the retina increases, dimmer targets will become visible, and the
brightness of the target at threshold will decrease. Therefore, as
retinal sensitivity increases, the differential light threshold, measured
in apostilbs, decreases.

This inverse relationship between retinal sensitivity and

threshold holds true throughout most of visual psychophysics. In
automated perimetry, however, threshold is recorded in the inverted

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decibel scale, and dimmer targets have higher decibel values. In this
way, threshold in decibels is directly proportional to retinal sensitivity.

2.3. APOSTILBS AND DECIBELS

In perimetry, the luminance of test targets is measured in

apostilbs. An apostilb is an absolute unit of luminance and is equal to
0.3183 candela/m2 or 0.1 mililambert.

Manufacturers of automated perimeters created the decibel

scale, which is a relative scale to measure the sensitivity of the island
of vision. It is an inverted logarithmic scale. Zero decibels is set as
the brightest stimulus that the perimeter can produce. The decibel
scale is not standardized because the maximal luminance varies
between instruments.

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3. VISUAL FIELDS AND GLAUCOMA

3.1. GLAUCOMATOUS VISUAL FIELD DEFECTS

Any clinically or statistically significant deviation from the normal

shape of the hill of vision can be considered a visual field defect. In
glaucoma, these defects are either diffuse depressions of the visual
field or localized defects that conform to nerve fiber bundle patterns.

3.2. DIFFUSE DEPRESSION

Diffuse depression of the visual field results from an overall or

widespread sinking of the island of vision and may reflect diffuse loss
of nerve fibers of the retina. Diffuse depression is a nonspecific sign
that can be caused by many etiologies other than glaucoma.

By far the most common reason for a diffuse depression is lens

opacity. Other factors include other media opacities, miosis, improper
refraction, patient fatigue, inattentiveness or inexperience with the
examination, ocular anomalies and age. It is difficult to attribute
diffuse depression specifically to a glaucomatous process.

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 In manual perimetry, diffuse depression is manifested by
contraction of the isopters. The isopters retain their normal contour.
The most central isopters may disappear entirely as the peak of the
island of vision sinks.

In automated perimetry, diffuse depression results in relative

defects across the entire visual field.

Early diffuse depression often is difficult to detect because

thresholds may remain within the normal range, but they may be
depressed from previous examinations or the baseline status.

3.3. LOCALIZED NERVE FIBER BUNDLE DEFECTS

Localized visual field defects in glaucoma result from damage to

the retinal nerve fiber bundles. Because of the unique anatomy of the
retinal nerve fiber layer, axonal damage causes characteristic
patterns of visual field damage.

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3.3.1. NERVE FIBER BUNDLE DEFECT

The superior and inferior poles of the optic nerve head are
most vulnerable to glaucomatous damage. It has been postulated
that these areas may be watershed areas at the junction of the
vascular supply from adjacent ciliary’s vessels.

Ultra structural examination of the lamina cribrosa shows that

the pores in the superotemporal and inferotemporal areas are larger.
The large pores may make these regions more vulnerable to
compression.

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3.3.2. PARACENTRAL DEFECTS

Circumscribed paracentral defects are an early sign of localized

glaucomatous damage. The defects may be absolute when first
discovered, or they may have deep nuclei surrounded by areas of
less dense involvement. The dense nuclei often are numerous along
the course of the nerve fiber bundle.

3.3.3. ARCUATE SCOTOMAS

More advanced loss of arcuate nerve fibers leads to a scotoma

that starts at or near the blind spot, arches around the point of
fixation and terminates suddenly at the nasal horizontal meridian. An

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arcuate scotoma may be relative or absolute. In the temporal portion
of the field, it is narrow because all of the nerve fiber bundles
converge onto the optic nerve. The scotoma spreads out on the nasal
side and may be very wide along the horizontal meridian.

3.3.4. NASAL STEP DEFECTS

Because of the anatomy of the horizontal raphe, all complete

arcuate scotoma send at the nasal horizontal meridian. A step like
defect along the horizontal meridian results from asymmetric loss of
nerve fiber bundles in the superior and inferior hemifields.
Nasal step defects may be evident in some isopters but not in
others, depending on which nerve fiber bundle is damaged. The
width of the nasal step also varies. Nasal steps frequently occur in
association with arcuate and paracentral scotomas, but a nasal step
also may occur in isolation.
Approximately 7% of initial visual field defects are peripheral
nasal step defects.

3.3.5. TEMPORAL WEDGE-SHAPED DEFECTS

Damage to nerve fibers on the nasal side of the optic disc may
result in temporal wedge-shaped defects. These defects are much
less common than defects in the arcuate distribution. Occasionally,

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they are seen as the sole visual field defect. Temporal wedge defects
do not respect the horizontal meridian.

3.4. EARLY VISUAL FIELD DEFECTS

Initial localized visual field defects may be either relative or

absolute. In 35 eyes with previously normal visual fields, Werner and
Drance found 15 eyes that the earliest defects were paracentral

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scotomas with a nasal step (51%), isolated paracentral defects
(26%), isolated nasal steps (20%) and sector defects (3%).

Hart and Becker found the following initial visual field defects in
98 eyes: nasal steps (54%), paracentral or arcuate scotomas (41%),
arcuate blind spot enlargement (30%), isolated arcuate scotomas
separated from the blind spot (20%), and temporal defects (3%).

Early visual field defects

> Arcuate scotomas > Isolated paracentral scotomas

>Tend to elongate circumferentially > Nasal (Roenne) step

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 Advanced visual field defects

> Development of ring scotoma > Peripheral and central spread

> Residual central island > Residual temporal island

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3.5. BLIND SPOT CHANGES

ENLARGEMENT
Vertical elongation of the blind spot may occur with the
development of a Siedel scotoma, an early arcuate defect that
connects with the blind spot. Peripapillary atrophy, which frequently
accompanies glaucomatous damage, particularly in elderly patients,
also may cause enlargement of the blind spot.

BARING
Baring of the blind spot may be physiologic or pathologic.
Physiologic baring of the blind spot is an artifact of kinetic perimetry.
The inferior retina is less sensitive than the superior retina, so an
isopter plotted at threshold in the inferior central retina may result in
superior baring of the blind spot. Physiologic baring of the blind spot
usually is confined to a single central isopter in the superior visual
field.

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3.6. COMMONLY USED PROGRAMS FOR GLAUCOMA.

Commonly used programs for glaucoma are the Octopus program

32 and the Humphrey program 30-2. These programs are tests of the
central 30° with 6° of separation between locations. Humphrey
program 24-2 eliminates the most peripheral ring of test locations
from program 30-2, except in the nasal step region, and tests only the
central 24°. This test is very useful because the peripheral ring of
thresholds provides the least reliable data, and testing time can be
shortened.

3.7. REFRACTIVE ERRORS

Uncorrected refractive errors cause defocusing of the test

target and apparent depression of retinal sensitivity. Each diopter of
uncorrected refraction causes a 1.26-db depression of retinal
sensitivity.
The proper near add refraction, as determined by the patient's
age and the diameter of the perimeter's cupola, must be used. This
lens must be positioned properly to prevent artifactual defects caused
by the rim of the lens.

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3.8. CATARACTS AND OTHER MEDIA OPACITIES

Media opacities, such as cataracts, can cause generalized

depression of the visual field. As cataracts become more dense,
visual field defects may appear to worsen. It is important to check for
changing acuity, worsening of cataracts, and other media opacities
when analyzing visual fields for progression.

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4
4. TESTING PARAMETERS

4.1. ASSESSING RELIABILITY

False-Positive Catch Trials

A sound cue is given before each stimulus is presented.
Periodically, the sound cue is given but no test stimulus is presented.
A false-positive result occurs if the patient responds to the sound cue
alone.

False-Negative Catch Trials

A false-negative catch trial is recorded if a patient does not
respond at a location that had a measurable threshold earlier in the
examination. A high number of false-negative catch trials may
indicate patient inattentiveness and an unreliable visual field. The
false-negative response rate is higher in eyes with extensive visual
field defects than in those with normal visual fields.

4.2. GLOBAL INDICES

The mean deviation (HFA) or mean defect (Octopus) reflects the

overall depression or elevation of the visual field. The deviation from
the age-matched normal value is calculated at each location in the

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visual field. The mean deviation is simply the average (Octopus) or
the weighted average (HFA) of the deviation values for all locations
tested. Like the mean sensitivity, the mean deviation is most
sensitive to diffuse changes and is less sensitive to small-localized
scotomas.
Pattern standard deviation (HFA). Such irregularities can be due
to a localized visual field defect or to patient variability. The corrected
loss variance or corrected pattern standard deviation provides a
measure of the irregularity of the contour of the hill of vision that is
not accounted for by patient variability (short-term fluctuation). It is
increased when localized defects are present.

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4.3. INTER EYE COMPARISONS

The difference in the mean sensitivity between a patient's two

eyes is less than 1 db 95% of the time and less than 1.4 db 99% of the
time.

Inter eye differences greater than these values are suspicious, if

they are unexplained by non-glaucomatous factors, such as unilateral
cataract or miosis.

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5. TESTING THE PATIENT

5.1. VISUAL FIELD TESTING (PERIMETRY)

Visual field tests are designed to map a person’s visual field, to

document the level of peripheral vision. As most glaucoma patients
know, the test consists basically of responding every time a flash of light
is perceived, all the while looking straight ahead. Understanding the
various parts of the printout of the results, such as shown here, is one
way of understanding more about visual field testing.

A. Test Type

The ideal visual field test would be easy to take, easy

to administer and 100% reliable. We have no such test, but
fortunately for everyone involved, recent years have seen

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substantial improvements in all of these areas. Especially
welcome to the glaucoma patient are tests that are faster
and less tedious.

The modern Eye Hospitals nowadays, relay almost

completely on Humphrey automated perimeters, often using
a new testing program known as SITA. This test can be
completed anywhere from about 3 to 8 minutes depending
on whether the SITA Fast or SITA Standard program is used.
This new program is not useful for all patients and some are
still tested using older, but still excellent, strategies.

B. Patient information

The patient’s visual acuity and age are important

factors in obtaining reliable results test must be taken with
the appropriate correction needed for close vision. Also,
since the retina of the normal eye becomes less sensitive
with age, it is important that the age of the person being

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tested be taken into account. When reviewing a visual field
test printout it’s worthwhile for the patient to check to see if
these figures are correct.

C. Reliability Parameters . The visual field

The print-out provides three kinds of information to help the

clinician assess just how reliably a visual field test reflects
the patient’s actual visual field:

(1) Fixation losses. It is very important that

the patient keep the eye being tested focused
straight ahead while taking a visual field test.
The examiner wants to know what the peripheral
vision is like, that is vision off to the sides -- up
and down, right and left. In practice it is difficult
to maintain this eye position for very long, since
the natural tendency is to look to the side,
towards the flashing light. But because many

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such movements may make the test unreliable,
the machine records how many times the patient
moves his eye off center.

(2) False Positives Errors. Sometimes the

patient will push the button indicating he has
seen a flash when in fact no flash has been
shown. This misinformation obviously seriously
detracts from the test\s ability to determine what
the patient is actually seeing. One reason why
the patient may indicate he has seen something
even though nothing has been shown is that, like
all of us, he wishes to do well on tests. The
machine is designed to test for this tendency by
making the normal beep or whirr but presenting
no light, tempting the patient to click the button
inappropriately. Even two false positives may
make a test unreliable.

(3) False Negative Errors. To further gauge

reliability, the test repeats flashes at the same
spot at the same and at different levels of
intensity. If one time the patient reports seeing a
flash at a certain spot, but does not report
seeing the same intensity flash at the same spot
the second time it is shown, the reliability of the

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 test is reduced. People who have glaucoma may
have normal fluctuations at the edge of their
visual field loss, so not all of these kinds of errors
are truly a problem.

D. Retinal sensitivity is not an all-or-nothing affair.

Sometimes a relatively weak flash at a particular spot that
could not be seen becomes visible if the intensity of the light
is increased. By flashing lights of varying intensity, the
machine can ascertain the level of retinal sensitivity at each
representative point in the visual field. The numbers on the
printout diagram indicate the level of intensity required to
enable the patient to see the flash. The higher the number,
the dimmer the light that could be seen.

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 Visual Field Enlarged View

E. A nice picture of a patient’s visual field is obtained by assigning a

lighter shade of gray to spots on the visual field in which a patient could
see relatively weak flashes (the higher numbers in "D"), and a darker
shade of gray to spots in which a patient could see only relatively strong

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flashes. Here it is appropriate to point out that all eyes have a blind spot
(scotoma) where the optic nerve connects with the retina. It is "blind"
because there are no light receptors at this point. The blind spot in the
eye shown is indicated by the dark area in the lower left half in this
printout.

38
 Visual Field Enlarged View

F. As pointed out in B, retinal sensitivity diminishes with age. The dark

boxes in this diagram indicate areas in which the person saw less well
than most people his age.

39
 G. Many conditions other than glaucoma can cause poor
vision, for example cataract or corneal edema. So, if the clinician wants
to know how much of a patient’s relative insensitivity to light is due to
glaucoma rather than to something else, it is important to "subtract out"
these other factors. This can be done because these other conditions
tend to produce a similar pattern of diffuse visual field loss, while
glaucoma tends to produce localized areas of visual field loss.

40
H. These numbers indicate the extent to which the visual field is outside
normal limits. They can be followed over time to see the extent to which
it is worsening.

41
 There are many reasons other than glaucoma for an abnormal
visual field result: the test was poorly given, the instrument was
defective, the patient did not understand how to take the test, the
patient was tired, the defect was real but does not indicate pathology,
the defect is accounted for by some pathology other than glaucoma,
e.g., brain tumor, multiple sclerosis, a vascular problem, a congenital
defect, an infection, or retinal disease such as macular degeneration,
retinal detachment or inflammation. Or the defect could be a false
defect, that is really not present at all!

Despite all of the shortcomings of visual field testing it is the only

way to document actual visual loss and whether such loss is progressing
or remaining stable. As such it plays an essential role in helping
glaucoma patients retain their sight.

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5.3. CONCLUSIONS ABOUT VISUAL FIELD TESTING ROUTINE

There are a variety of methods utilized to measure the visual fields.

Virtually all visual field testing is performed one eye at a time, with the
opposite (contra lateral) eye completely covered to avoid errors. In all
testing, the patient must look straight ahead at all times in order to
avoid testing the central vision rather than the periphery. Most modern
visual field testing devices also continuously monitor fixation, or the
ability of the patient to maintain a consistent straight ahead gaze. To
summarize, visual field testing is useful for plentiful reasons:

• screening for glaucoma,

• testing patient with glaucoma for treatment response,
• testing for macular diseases such as macular degeneration or
toxicity from certain medications such as Plaquenil used for
rheumatoid arthritis,
• testing for peripheral retinal disease such as retinal detachment or
retinitis pigmentosa,
• testing the function of the optic nerve looking for tumor, injury,
poor circulation or stroke, compression from swelling in the eye
socket or orbit, or severe dietary deficiency,
• testing the visual pathways to the brain, looking for tumor, brain
swelling, injury, or poor circulation, and
• testing the visual or occipital cortex, looking for tumor, injury,
brain swelling, or poor circulation.

43
 Having the patient look straight ahead and count the fingers shown
by the examiner from the side can do a crude visual field test. However,
more typically, visual fields are measured by a computerized assessment
in an optometrist's, ophthalmologist's or neurologist's office. For these
procedures, one eye is covered and the patient places his or her chin in
a bowl-shaped chin rest. Then, when the patient sees lights or
movement of various intensities and at different locations, he or she
pushes a button. In all standardized testing, the right eye is tested first,
followed by the left eye. This process produces a computerized map of
the visual field.

Thus, visual field testing can be grouped into several important

categories:

• Confrontational: The test is given one on one by a doctor or

technician as a screening tool, in which peripheral finger
movements are brought from the far periphery to the near
periphery in four quadrants
• Amsler grid: It's an important tool to test macular vision in and
around the center of the retina and detect specific conditions such
as macular degeneration
• Static perimetry: The most common type of modern visual field
testing employs a device with fixed light sources, either stationary
pinpoint light sources or projected dots within a large white bowl.
Popular devices include the Octopus or the Humphrey-Zeiss field
analyzer. These tests are automated and run by the onboard

44
 computer, thus minimizing the time spent by a technician running
the test.
• Kinetic perimetry: The process utilizes moving light sources,
such as the traditional workhorse Goldman perimeter. This test
produces an island map of peripheral visual perception intensity.
Fixation monitoring as well as movement of the light source
require a dedicated trained technician throughout the entire test.
This test is particularly useful in weeding out malingerers.
• Frequency doubling analysis: This test utilizes varying
intensities of a shimmering grid of light in standardized sectors of
the peripheral and central visual field. It is particularly useful in
detecting early glaucoma field loss and can be about 40% more
sensitive in doing so than standard static or kinetic perimetry.

Visual field testing is generally covered by virtually all health-care

insurance plans. Testing may be limited to one time per year for
patients who are called glaucoma suspects, that is likely to develop
glaucoma in the future. Insurance plans usually allow two visual field
tests per year for patients who have already been diagnosed with
glaucoma.

These visual field testing devices all incorporate an internal computer

with the ability to store, print, and transmit important patient data. The
field report generated by modern visual field devices includes a wealth
of information, all of which can be useful to the examiner interpreting
the results:

45
• Fixation errors: the number of times the patient looks away
from the central target. This is a key indicator of patient
cooperation or fatigue.
• False positives: the number of times the patient pushes the
button when, in reality, a light source is not illuminated.
• False negatives: the number of times the patient fails to push
the button when, in reality, there is a light source illuminated.
These spots can be repeat tested by the onboard computer at
exactly the same spot to best understand the patient's ability to
produce an accurate field test.
• Points tested: indicates the total number of separately
illuminated testing points, and therefore data points presented to
the patient for testing. Reliable patients can produce a very useful
field with a limited number of test points.
• Reliability index: the overall reliability of the patient's testing for
each eye. Poor reliability may indicate patient fatigue, insufficient
understanding of the test, or poor vision for other reasons such as
cataracts. Visual field tests can also be used to ferret out
malingerers.
• Standard deviation: the difference in peripheral field acuity
when compared to a normative data base, or simply put a large
group of similar normal patients. This tells the examiner whether
or not a particular part of the peripheral field is normal, depressed
or absent.

46
 • Visual field map: the final basic report indicating the patient's
visual field anywhere from the central 10 degrees all the way out
to the farthest reaches of the field at 90 degrees. Altered patterns
in the field map from reliable patient testing are often extremely
useful in the diagnosis of ocular or neurological disorders.

The clinician generally performs after visual acuity testing, but before
examination, the visual field test. Visual field testing requires a minimal
amount of time for most otherwise healthy patients, but it may be
moderately tiring or stressful for ill or elderly patients. Visual field
testing is also very difficult for younger children or patients with mental
disabilities or developmental delay, such as Down's syndrome for
example. Common testing time for visual fields in both eyes:

• Amsler grid: one minute

• Confrontational field: two minutes
• Static field for glaucoma screen: eight minutes
• Static field for complete glaucoma evaluation: 15 minutes
• Kinetic Goldman field for complete glaucoma evaluation: 20
minutes
• Frequency doubling analysis for glaucoma screen or evaluation: 10
minutes

47
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