VISUAL FIELD

CHANGES IN
GLAUCOMA
DR OLORUNDARE O. K.
19/01/2011
OUTLINE
INTRODUCTION
RELEVANT ANATOMY
THE NORMAL VISUAL FIELD
VISUAL FIELD TESTING
VISUAL FIELD DEFECTS
CONCLUSION
INTRODUCTION
Glaucoma
a group of conditions defined by a progressive optic
neuropathy with accompanying visual field changes.
Raised IOP is classified as a risk factor.
A leading cause of irreversible blindness
Modalities of evaluating/monitoring
Intra-ocular pressure
The optic disc appearance
The visual field

RELEVANT ANATOMY
OPTIC NERVE HEAD
Neuroretinal rim
Cup
Blood vessels

Neuroretinal rim
the tissue between the outer edge of the cup and the
disc margin.
The normal healthy rim has an orange or pink colour
.
Characteristic configuration.(ISNT)


RELEVANT ANATOMY



RELEVANT ANATOMY
Optic Cup
the central portion of the disc that is not occupied by
fibres.
The size of this cup is dependent on
the size of the scleral opening
the number of fibres passing through.

Cup-disc ratio
the diameter of the cup expressed as a fraction of the
diameter of the disc
measured in both vertical and horizontal meridians
Most normal eyes have a vertical cup-disc ratio of 0.3 or
less:

RELEVANT ANATOMY
RELEVANT ANATOMY
Retinal nerve fibre layer
nasal half of the retina srf and irf
macular area papillomacular bundle
temporal retina superior and inferior arcuate fibres
with a horizontal raphe in between

Within the optic nerve head
from the peripheral part of the retina
Most peripheral (superficial) part of the optic disc.
fibres originating closer to the nerve head
more central(deep) portion of the disc.
RELEVANT ANATOMY
Within the optic nerve head
Arcuate nerve fibres
the superior and inferior temporal portions of optic
nerve head
most sensitive to glaucomatous damage

Macular fibres
most resistant to the glaucomatous damage
retention of the central vision till end.
RELEVANT ANATOMY
Distribution of retinal
nerve fibres
RELEVANT ANATOMY
Arrangement of
nerve fibres within
optic nerve head
THE NORMAL VISUAL FIELD
The field of vision
the area that is perceived simultaneously by a
fixating eye.
a three-dimensional area of a subjects
surroundings.
described as an island of vision in the sea of
darkness .
the island of vision has a steep central peak that
corresponds to the fovea.
The limits of the normal field of vision
60 superiorly
60 nasally
80 inferiorly
90 temporally
The blind spot is located temporally between 10 and 20.
THE NORMAL VISUAL FIELD
THE NORMAL VISUAL FIELD
The visual field can be divided into
Central field
area from the fixation point to a circle 30 away.
contains physiologic blind spot on the temporal side

Peripheral field of vision
The area beyond 30 to outer extent of the field
ofvision.


VISUAL FIELD TESTING
a.k.a as Perimetry
Designed to map a persons visual field, to document
the level of peripheral vision.

Definition of Terms
An isopter.
the contour lines on a map which enclose an area within
which a target of a given size is visible
An absolute scotoma
an area of total visual loss in which even the largest and
brightest target cannot be perceived.



VISUAL FIELD TESTING
Definition of Terms
A relative scotoma
area of partial visual loss within which brighter or larger
targets can be seen and smaller or dimmer ones can not.
Luminance
the intensity or 'brightness' of a light stimulus. measured in
apostilb (asb).
A decibel (dB) is a non-specific unit of luminance.
Visible threshold
the luminance of a given stimulus at which it is perceived
50% of the time when presented statically


VISUAL FIELD TESTING
Types of perimetry
Kinetic perimetry.

the stimulus of known luminance is moved from
periphery towards the centre to establish isopters.

Methods
Confrontation method,
Listers perimetry,
Tangent screen scotometry
Goldmanns perimetry

VISUAL FIELD TESTING
Types of perimetry
Static perimetry.
forms the basis of modern glaucoma assessment.
A stimulus is presented at a predetermined position for
a preset duration with varying luminance.

Methods
Automated perimetry
Friedmann perimetry


VISUAL FIELD TESTING
Types of perimetry
Manual Perimetry
Most of the kinetic methods of field testing are done
manually
Methods
Confrontation Method
Listers Perimeter
Campimetry

Automated Perimetry
computer assisted and test visual fields by a static method
test suprathreshold and threshold stimuli and quantify depth
of field defect

VISUAL FIELD TESTING
Types of perimetry
Automated Perimetry
Commonly used automated perimeters are:
Octopus Field Master
Humphrey field analyser
Two basic testing strategies are used in automated
static perimetry
Suprathreshold testing.
uses targets that are well above the brightness that the
patient should be able to see.
a screening procedure to detect gross defects.




VISUAL FIELD TESTING

Types of perimetry
Testing strategies are used in automated static
perimetry
Threshold testing.
Provides more precise results
preferred by most clinicians,
takes more time and the equipment often costs more.







VISUAL FIELD TESTING
Evaluation of Humphrey single-field print-out
Uses a software called Statpac printout
Can be studied in parts or zones

1. Patient data and test parameters
Patients data (name, date of birth, eye (right/left) pupil
size visual acuity).
Test parameters (test name, strategy, stimulus used,
background)









VISUAL FIELD TESTING
Evaluation of Humphrey single-field print-out
2. Reliability indices
examination is considered unreliable if 3 of the
following reliability indices have below mentioned
values
Fixation losses 20%,
False positive error 33%,
False negative error 33%,
Short-term fluctuations 4.0 dB,
Total questions 400.









VISUAL FIELD TESTING
Evaluation of Humphrey single-field print-out
3. Gray scale
provides the field defects at a glance
The darker the printout, the worse is the field.

4. Total deviation plots
provide the deviation of patients threshold values from
that of age corrected normal data.
Numeric value plot and the probability plot
An indicator of the general depression and cannot reveal
hidden scotomas








VISUAL FIELD TESTING
Evaluation of Humphrey single-field print-out
5. Pattern deviation plots.
adjusted for any generalized depression in the overall field
which might be caused by factors such as lens opacities or
miosis.

6. Global indices
provide overall guidelines to assess the field results as a
whole rather than on point-to-point basis
used to monitor progression of glaucomatous damage
rather than for initial diagnosis










VISUAL FIELD TESTING
Mean deviation (MD)
the mean difference between the normative data for
that age compared with that of collected data
Worse than normal value is indicated by a negative
value

Pattern standard deviation (PSD).
a measure of variability within the field
points out towards localized field loss
most useful in identifying early defects.

VISUAL FIELD TESTING
Corrected pattern standard deviation (CPSD).
indicates the variability between adjacent points that
may be due to disease rather than due to intra-test
variability.

7. Glaucoma hemifield test (GHT)
compares identical 5 clusters of points in the upper
field (above the horizontal midline) with the 5 in the
lower field

8. Probability Values
indicates the significance of the defects


VISUAL FIELD TESTING

8. Probability Values
indicates the significance of the defects
shown as < 5%, < 2%, < 1% and < 0.5%
The lower the P value the greater its clinical
signiflcance


VISUAL FIELD TESTING
Humphrey Display
VISUAL FIELD TESTING
VISUAL FIELD TESTING
Sources of error
Miosis
s threshold sensitivity of the peripheral field
Pupils less than 3mm in diameter should be dilated prior to
perimetry.
Lens opacities
Uncorrected refractive error
cause a significant decrease of central sensitivity.
Spectacles
Can cause rim scotomas if small aperture lenses are used
Ptosis
can result in suppression of the superior visual field
Inadequate retinal adaptation
VISUAL FIELD DEFECTS
Visual field defect
Any clinically or statistically significant deviation from
the normal shape of the hill of vision
Defects can either be
diffuse depressions of the visual field
localized defects that conform to nerve fiber bundle patterns

Visual field defects in glaucoma are initially
observed in Bjerrums area (10-25 from
fixation)
VISUAL FIELD DEFECTS
The natural history of the progressive
glaucomatous field loss

Isopter contraction
mild generalised constriction of central as well as
peripheral field
the earliest visual field defect occurring in glaucoma.
of limited diagnostic value.
VISUAL FIELD DEFECTS
Baring of blind spot.
exclusion of the blind spot from the central field due to
inward curve of the outer boundary of 30 central field
very non-specific
of limited diagnostic value

Paracentral scotoma
the earliest clinically significant field defect.
may appear either below or above the blind spot in
Bjerrum's area


VISUAL FIELD DEFECTS
A. Baring of blind spot;
B. Superior paracentral
scotoma;
C. Seidel's scotoma;
D. Bjerrum's scotoma;
E. double arcuate
scotoma and
Roenne's central nasal
step
VISUAL FIELD DEFECTS
Arcuate or Bjerrums scotoma
formed by the extension of Seidels scotoma in an area
either above or below the fixation point
reaches the horizontal line

Ring or double arcuate scotoma
Develops when the two arcuate scotomas join together

Roenne's central nasal step
created when two arcuate scotomas run in different arcs
meet to form a sharp right-angled defect atthe horizontal
meridian

VISUAL FIELD DEFECTS
Advanced
glaucomatous field
defects
only a small island of
central vision (tubular
vision) and an
accompanying temporal
island are left

The temporal island of
the vision is more
resistant and is lost last
NPL

REFERENCES

Jack J Kanski, Ocular Examination techniques,
Clinical Ophthalmology, A Systematic
Approach, ch. 26
A. K. Khurana, Glaucoma, Comprehensive
Ophthalmology, p216 220
Jeffrey Henderer, Understanding Visual Field
Testing
Visual Fields in Glaucoma, ppt presentation
Dr Caroline Cobb, Glaucoma Evaluation
Tutorial; 2010, optic-disc.org.

THANK YOU