READING A SINGLE FIELD

OF AUTOMATED PERIMETRY
Siddarth sain

What is the visual field?

A three dimensional area seen
around an object of fixation
Perimetry is the procedure for
estimating the extent of the
visual field

Classic central full threshold

test

Original program of HFA-I introduced in 1984

30-2 strategy determines sensitivity in central
30 degrees at locations 6 degrees apart
Patient gazes at center of a diamond
projected at 10 degrees below fixation point
at center of the bowl
Size III stimulus for 0.2 sec
Wait for a response for about 1.8 sec
If no response, a stimulus 4 dB more intense
is presented
If there is a response, a stimulus 2 dB less
intense is presented until patient fails to
respond

Threshold testing

Classic central full threshold

test

Threshold is first determined at 4

primary locations one in each
quadrant symmetrically placed 9
degrees from both horizontal and
vertical meridian starting at 25 dB
These 4 points are tested twice

Classic central full threshold

test

In addition to the 4 mentioned, 6 more

random points are tested twice, a
total of 10 points, which are used to
calculate the short term fluctuation
To save time the initial stimulus
intensity at each point is extrapolated
from the sensitivity of the nearby
point
Any deviation from the expected
threshold more than 5dB leads to
retesting of the point

The Fastpac strategy

Introduced in 1991
Changes stimulus intensity in 3 dB
steps
More vulnerable to response errors
Higher intratest variability.
Requires 30% less time than full
threshold

The SITA strategy

Avilable as SITA std. and SITA fast
Uses pt. age ,normal and abnormal
database and pt. response to
calculate the expected results for
each point
Shorter testing time
Reduced normal variability

the supra threshold test

Screening mode
Faster then full threshold
Less informative
Do not provide quantitative data
Less often use in glaucoma

The single field print out

1. Test information
2. Reliability indices
3. Procedure and patient data
4. Numeric data
5. Gray scale
6. Total deviation plot
7. Pattern deviation plot
8. Glaucoma hemi field test
9. Global indices
10. Gaze tracker

Test information

Procedure and patient

data

Reliability indices

Fixation monitor and fixation

target

Blind spot indicates that the blind

spot was mapped first using the HeijlKrakau technique.
The blind spot is mapped early and
then test targets are intermittently
placed within the mapped area.
Any response indicates loss of
fixation

Fixation losses

If a patient is having fixation

losses he will see a stimulus in
the originally mapped blind
spot area
An acceptable upper limit is
20% losses
A field is reasonably reliable if
in presence of a high FL rate,
the FP,FN,SF rates are low

False positive responses

Represents the tendency of a patient to

respond not in response to seeing a
stimulus but in expectation of a stimulus or
in response to a non visual clue
Upper limit of acceptiblity is 33%
There will be some points of unusually high
sensitivities
Presence of white scotomas with points
having sensitivity thresholds of 40dB or
more on the numeric scale
The GHT will show abnormally high
sensitivity
MD will be strikingly high

False positive responses

False negative responses

Failure of a patient to respond to a

presented visual stimulus
Due to loss of concentration or fatigue
The measured threshold values come out to
be very low
Negative MD
Some points are randomly more affected
than others so PSD and SF are abnormal
Patches of depressed sensitivity occur at
the edge of the field which is tested last
Classical clover leaf pattern in grey scale

False negative responses

Raw Numeric data

Represents the actual threshold
values for the various points.
At least 10 points are tested
twice. Any point that is 5 dB
above or below the expected
value is also retested.
This data provides the basis for
the entire visual field.

Numeric data

Gray scale
Points on the gray scale are calculated from the
points on the numeric data.
They give an immediate and easily comprehensible
picture.
Useful in highlighting the common artifactual field
loss.
The change is gray scale may be falsely dramatic as
it is a smoothened out picture based on
extrapolation of just 76 points
.
Shallow defects can be missed .
.

Gray scale

Total deviation

Compares the patients visual field

with a bank of normal data for a
patient of same age.
2 parts :
The decibel plot represents the
deviation rounded to the nearest
integer from the mean normal value for
that persons age.
A deviation of 5dB is taken as
abnormal.
The normal range is larger in the
periphery and also larger superiorly.

The probability plot

Symbols depict the frequency of the

value within the normal population
of that age.
The TD is good at identifying the
overall visual field loss but of limited
value in determining focal defects if
a generalized depression is present.

Total deviation

Pattern deviation
Determined by correcting the
field for overall depression.
The seventh most sensitive non
edge point is used to adjust the
hill of vision.
Helps in identifying a focal
defect from glaucoma in a
patient with a field depressed
by other causes e.g. a cataract.
.

Pattern deviation

A catch in the PD
The PD plots are based upon the
sensitivities of the best points in the TD
plot. Therefore if the best points are almost
blind then PD wont help. (look for the gray
scale).
During early stages the subtle defects will
be picked up, but as the glaucoma
advances the generalized depression sets
in. So the PD can be misleading.
In end stage glaucoma the plot might
actually reverse. Have a look at the
fundus.

Glaucoma hemifield test

This looks at the cluster of points above
and below the horizontal to see if there is
any significant difference between the
mirrored points.
This difference is the hallmark of
glaucomatous damage. The GHT analyzes
the difference in terms of deviation from
controls and translates them into the
probability domain, for the whole central
field.
Five zones are compared like this. Score is
assigned to each zone depending upon the
percentile deviation in the PD plot of the
group of points in the zone.

Glaucoma hemifield test

Readings in the GHT

GHT describes the field as
Within normal limits
Generalized reduction
Abnormally high sensitivity
Outside normal limits
borderline

Global indices
1.
2.
3.
4.

MEAN DEVIATION
PATTERN STANDARD DEVIATION
SHORT TERM FLUCTUATION
CORRECTED STANDARD PATTERN DEVIATION

Any global index of p value less

than 5% has a high probability of
being abnormal.

 MEAN DEVIATION :

1)calculates the mean of deviation in the patients

results from the age corrected normal database.
2) The MD is mainly an index of the size of the visual
field defect, more sensitive to generalized field defect

PATTERN STANDARD DEVIATION :

It is the difference between a given point
and its adjacent points.

SHORT TERM FLUCTUATION:

Expression of variability between two
different evaluations of the same
patient. A high number indicates low
patient reliability.
It is estimated from the test retest
differences at 10 standard locations.
Usually ranges from 2 to 3 dB
normally.
Important to note that it may be the
first sign of glaucomatous damage.
( edge of scotoma)

CORRECTED PATTERN STANDARD

DEVIATION: is the PSD corrected for SF.
A high SF will give rise to a CPSD lower
than the PSD.
It is an index of localized non uniformity of
the hill of vision.
In general:
1) normal MD and CPSD = probably
normal field
2) abnormal MD and normal CPSD=
generalized loss
3) normal MD and abnormal CPSD=
localized defect
4) abnormal MD and CPSD= large defect
with a
localized component

Gaze tracker
Present in the newer machines.
Follows the patients cornea and
records the movements.
More spikes and taller spikes
indicate greater deviation.
Downward spikes represent the
situation when fixation was
unrecordable.

Criteria for minimum

abnormality

1. 3 or more contiguous, non edge

points in an expected location of the
field that have p<5% on the PD plot,
one of which must have p<1%.
2. GHT outside normal limits.
3. CPSD values seen < 5%
All of the above should be
on two consecutive fields

Progression of a field
NEW DEFECT:
1.A new cluster of at least 3 non edge
abnormal points arises in a typical
location, each with threshold
sensitivities occurring in fewer than
5% of the normal population(p<5%),
and with a sensitivity that occurs in
fewer than 1% of the population (p
<1%) at one of the points

Progression of a field

DEEPENING OF A PREEXISTING DEFECT: a

defect has deepened or enlarged if 2 or
more points within or adjacent to an
existing scotoma have worsened by at least
10dB or 3 times the average of SF,
whichever is larger.
GENERALIZED DEPRESSION:
1.Decline in MD that is significant at p<1%
level OR
2.CPSD showing an obvious trend based on
last 5 consecutive fields OR
3.Decline of >3dB at all points on two
consecutive fields.

How to follow up?

Establish a baseline field/fields

Two or three successive fields 4 weeks
apart that are reproducible are taken as
representative baseline
In case of severely contracted fields
concentrate on the central 20 or 10 deg
with the 10-2 or the macular tests
Usage of a larger pattern of points. Eg. If
the diagnosis was made with a 24-2 pattern
with most points abnormal,converting to a
30-2 may be helpful
Usage of a larger size V stimulus in cases
with high visual loss

OVERVIEW ANALYSIS
Displays aal visual fields of eye
in CHRONOLOGICAL order
including gray scale,numeric
data,probability plots ,visual
acuity,pupil size
Easier to scan a series of
examinations

OCTOPUS
Fankhauser(1975) was the
mastermind behind the first
OCTOPUS perimeter.
OCTOPUS 101 and OCTOPUS
300/1-2-3 are the current
available models

Test conditions

Originally the OCTOPUS perimeters

operated at 4 apostilbs.
OCTOPUS 300/1-2-3 can be
operated under normal
environmental light conditions,
hence background illumination was
increased to 31.4 apostilbs
Goldmann size III stimulus is used
In the low vision program size V
stimulus is used

 Octopus 32 measure retinal

sensitivity at 76 points in central 30
Octopus G1 measures retinal
sensitivity at 73 points
59 points in central 26 at threshold
level and 14 points b/w 30 -60 at
suprathreshold level

 More concentrated test locations in center

to find paracentral scotomas
No test location on horizontal and vertical
axis except central point
To avoid pseudo scotomas caused by
correction lens edges 59 central test points
are within 26 and not tradition 30
14 peripheral test locations with a
concentration on the nasal side (to better
detect nasal steps) are added if information
outside the central 30 are requested
without prolonging the test duration too
much. In this case the complete G1 has 73
test locations. If only the center 30 are
tested this program is also called G2X as in
the OCTOPUS 300series

Normal test strategy

Based on threshold of differential light sensitivity

Testing begins at 4 anchor points
Begins at age corrected normal values minus 4
decibels followed by 6dB increase in stimulus
luminance when there is no response
Thereafter process continues with brighter spots in
steps of 8 dB
After the first crossing of threshold the bracketing
process is reversed making the stimulus luminance
dimmer by 4dB
After a NO crossing again there is an increment by
2dB
Finally a 1dB adjustment is applied in opposite
direction to obtain d.l. sensitivity

Tendency oriented perimetry

(TOP)

Reduces examination time by 80%

TOP can be applied to flicker as well as blue
on yellow perimetry
The anatomic and topographic
interdependence of visual field establishes a
tendency between the thresholds of
neighbouring zones
Instead of questioning each individual point 46 times, the threshold at every location is
adjusted 5 times with only one question per
location
This is done by one direct question and four
by results from questions in neighboring
locations

 The examination starts at half the

normal value
Then testing proceeds with
bracketing applying steps in relation
to patients age corrected normal
value.
Finally a step in each direction to
determine the actual threshold of d.l.
sensitivity

BEBIE /CUMULATIVE DEFECT

CURVE

Help to assess the overall condition of

visual field at glance
59 points tested at full threshold (in
G1) are ranked from highest to lowest
sensitivity after age correction
A curve is obtained
Points on left represent better points
Those on the right the worse points

Octopus perimeters

MEAN SENSITIVITY- average of retinal

sensitivity measured at all points
MEAN DEFECT average defect of all
threshold points from age matched
normals,as shown in comparison chart
LOSS VARIANCE- is obtained from
individual deviations of all measured
locations with mean defect value
SHORT TERM FLUCTUATION
CORRECTED LOSS VARIANCE- taking
into account STF

Criteria to detect abnormality

statically

One nasal step difference of more than

10dB
Two neighboring defects of more than
10dB
Cluster of three non edge defects of
more than 5dB not connected to blind
spot
Three locations with less than 5%
probability
One location of less than 1% probability

THANKS