Field of vision

Jihan Abdallah

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The normal extent of field of vision
60nasally.
50superiorly
70inferiorly .
90 temporally

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 VISUAL FIELD
Visual sensitivity is greatest at the very center of
the field and decreases toward the periphery.
The part of environment where in a steadily
fixating eye can detect visual stimulus.
Photoreceptors and corresponding visual
pathways upto the periphery of retina away from
point of fixation.
Reflects topographic sensitivity of various foci on
retina and corresponding visual apparatus.

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 `
Factors affecting field of vision
1-Vision
2-Refractive status
3-Education , attentiveness, cooperation
4-real size of spots
5-distance from eye
6-Duration of stimulus
7-Background illumination
8-Stimulus intensity
9-Contrast
10-Colour
11-Patient factors
12-Light / dark adaptation

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 PHYSIOLOGICAL BLIND SPOT

Corresponding to optic nerve head

15 deg temporal to point of fixation

Span 5 deg horizontal

-- 7 deg vertical

Two thirds below the horizontal

meridian

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 VISUAL FIELD DEFECTS
Scotoma - this is a type of visual field defect. It
is a defect surrounded by normal visual field.
Relative scotoma - an area where objects of
low luminance cannot be seen but larger or
brighter ones can.
Absolute scotoma - nothing can be seen at all
within that area.
DEPRESSION : is an area of reduced sensitivity
without a surrounding area of normal
sensitivity

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 Generalized depression
(both peripheral and central contraction)
e g cataract

Hemifield defect :
- Hemianopias
homonymous
heteronymous

Altitudinal defect

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 Central scotoma
Centrocaecal scotoma

Arcuate scotomas
Seidel scotoma
paracentral scotoma
Bjerrum scotoma
Nasal step
Ring double arcuate
Barring of blind spot
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EXAMINATION TEST

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 STATIC
The location, size and duration of stimulus is kept constant and the
luminance is gradually increased until seen.
Actual estimation of sensitivity of each point is THRESHOLD.

SUPRA THRESHOLD stimulus used for screening.

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IMPORTANT :
one eye is tested at a time, other is occluded.

fixation of the patient has to be steady and is monitored throughout the test.
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 KINETIC
This presents a moving stimulus from a
non-seeing area to a seeing area.
The most commonly used kinetic test is
Goldmann perimetry.
It is repeated at various points around the
clock and a mark is made as soon as the
point is seen. These points are then joined
by a line (an isoptre).

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Standard automated
perimetry
HUMPHREY FIELD ANALYZER

STATIC perimetry

Measurement of threshold values

Comparison to normative data

Inbuilt program for analysis diagnosis and progression

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 ADVANTAGES
Removal of examiner variability
More sensitive to subtle field defects

Retests abnormal points automatically

Gives reliability parameters like
fixation monitoring
Gaze tracking
False positive
False negative

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 PROGRAMS / PATTERNS
30-2 gold standard
24-2
10-2
MACULAR

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MACULA PROGRAM :16
locations within the central 5
with 2 spacing. Each location
is tested three times
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 Requirements
Selection of adequate test
Proper environment
Comfortable sitting position
Adequate size of pupil >3mm
Adequate Near correction
Proper explanation
Reassurance not all points will be seen
- test can be paused by keeping the response button
pressed

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 ZONE 1 : Patient data&Test data

Test data
Patient data Date and time
Name, DOB, eye Program and strategy
Vision, refraction, Background
Pupil diameter illumination
Test size, color,
duration, interval
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 ZONE 2 : RELIABILITY
Fixation monitor
Fixation target central
Test duration

Reliability indices
Fixation losses <20 %
Gaze tracking

False positives < 33%

(trigger happy)
False negatives < 33 %

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 Fixation loses= gaze monitor
Steadiness of gaze during test
Presenting stimuli to the blind spot.

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 False positive
Stimulus with a sound.
If the sound alone is presented &the patient
still responds.
False negative
Stimulus brighter than thershold.

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 ZONE 3 : GREY SCALE
Based on actual threshold values at each
location
General identification
Patient information

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ZONE 4 :TOTAL DEVIATION PLOT

Numerical plot indicates by

how much decibels in each
point depressed compared to
mean value in normal
population of similar age

Generalized depression due to

media opacities, refractive
error, miosis affect appearance
of a pattern
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ZONE 5 : PATTERN DEVIATION PLOT
calculated by adjustment for
generalized depression or elevation of
visual field

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 ZONE 6 : GLOBAL INDICES
single numbers to denote whole field
MEAN DEVIATION : average loss of sensitivity
from normal age matched population.

PATTERN STANDARD DEVIATION :is a measure

of focal loss.
- Range over which change of sensitivity at all
the points has occurred, along with probability
-compensates for effect of generalized
depression or elevation of field on mean
deviation value
local defects affect PSD > MD

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 ZONE 7 : GLAUCOMA HEMIFIELD
TEST

Comparison of 5 corresponding of points in

superior hemifield with mirror images in inferior
hemifield
as glaucomatous change is:
Vertically asymetrical.

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OUTSIDE NORMAL LIMITS
all cluster pairs differ @ p < 1% OR
1 cluster pair differs @ p < 0.5%

BORDERLINE
hemifields differ @ p < 3%

GENERAL REDUCTION OF SENSITIVITY

overall field depressed @ p < 0.5%

ABNORMAL HIGH SENSITIVITY

overall field elevated( best 15 % points)

WITHIN NORMAL LIMITS

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 ARTEFACTS

RIM ARTEFACTS
PTOSIS
MEDIA OPACITIES

MIOSIS

Refractive error
High power plus and minus lenses

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 high

High false negative score 29

 common causes of VF defect
Central field loss occurs with:
Optic neuropathy
Macular degeneration
Macular hole
Cone dystrophies
A number of rare conditions like Bests
disease, Stargardt's disease and
achromatopsia.

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Peripheral field loss occurs with:
Retinitis pigmentosa
Chorioretinitis
Glaucoma
Retinal detachment
Leber's optic atrophy

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 Focal field defects in optic
neuropathies
Central scotoma
Demyelination
Toxic and nutritional
Leber hereditary optic neuropathy
Compression

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 Focal field defects in optic
neuropathies
Enlarged blind spot
Papilloedema
Congenital anomalies
Respecting horizontal meridian
Anterior ischaemic optic neuropathy
Glaucoma
Disc drusin
Upper temporal defects not respecting
vertical meridian
Tilted discs.
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 Field defects in MS
Diffuse depression of sensitivity.
Altitudinal / arcuate defects.
Focal centrocecal scotomas
Focal defects with generalized depression.

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 Visual field defects in psoriasis
Central scotoma ,non specific paracentral
relative visual field defects
probably induced by toxic posterior optic
neuropathy.
The scotoma incompletely resolved after
cessation of Methotrexate (MTX) therapy.

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 Visual field defects in diabetic
retinopathy
Foveal thresholds were unaffected in the
diabetic patients but there is significant
reductions in visual field sensitivity.

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 Nutritional optic neuropathy
Field defects
Bilateral relatively symmetrical centrocaecal
scotomas
The margins of the defects are difficult to
define with a white target but easier using
red target.

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 Lesions before the chiasm
These will produce a field deficit in the ipsilateral
eye.
Field defects from damage to the optic nerve
tend to be central, asymmetrical and unilateral.
Lesions just before the chiasm can also produce a
small defect in the upper temporal field of the
other eye
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 Lesions at the chiasm
Bitemporal hemianopia.
If they spread up from below,
for example, pituitary tumours,
the defect is worse in the
upper field.
If the tumour spreads down
from above , e.g.
craniopharyngioma, the lesion
is worse in the lower
quadrants.
 Chiasmal tumor
Visual loss may precede optic atrophy.
Pupils usually react sluggishly to light.
Afferent pupillary defect is usually present.
Visual fields are abnormal.

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Pituitary adenomas a bitemporal
hemianopsia.

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 Lesions after the chiasm

These produce homonymous field defects.

A lesion in the right optic tract produces left visual
field defect.
Lesions in the main optic radiation cause
complete homonymous hemianopia without
macular sparing.
Lesions in the temporal radiation cause congruous
upper quadrantic homonymous hemianopia
commonly with macular sparing.
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 Lesions in the parietal radiation (rare) cause
inferior quadrantic homonymous hemianopia
without macular sparing.
Lesions in the anterior visual cortex (common)
produce a contralateral homonymous hemianopia
with macular sparing .
Lesions in the macular cortex produce congruous
homonymous macular defect
Lesions of the intermediate visual cortex produce
a homonymous arc scotoma, with sparing of both
macula and periphery.
right superior quadranopsia 46
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 Occipital lobe lesions

If both occipital lobes are injured then the patient

is in a state of cortical blindness.
some patients deny their blindness and attempt
to behave as if they have vision.
Markedly decreased vision and visual field in both
eyes (sometimes no light perception).
With normal pupillary responses.
Bilateral occipital lobe infarctions.
 Checkerboard Visual Field Defect: Bilateral
quadranopsia caused by two separate lesions
one above the calcarine fissure on one side of
the brain and one below on the opposite side
can produce a checkerboard pattern. This can
occur from two simultaneous events or events
separated in time.

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 A congruent visual field defect presents with
the same exact shape in the field of both eyes.
Visual fields that are different in shape are
considered incongruent.
More incongruent fields may point towards
lesion of the optic tracts
while congruent defects point more towards
the visual cortex of the occipital lobe.

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 Pupillary reflexes
Pontine hge pinpoint pupil
Midbrain lesiondilated fixed pupil.
Dorsal tectal lesionslight -near dissociation.

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 Light-near dissociation
Compressive lesion as pinealoma
involves the dorsal pupillomotor fibers
Sparing ventral fibers concerning with near
reaction.

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 Differential Diagnosis of Light-
Near Dissociation
Bilateral optic neuropathy or severe retinopathy:
Reduced visual acuity with normal pupil size.
Adie (tonic) pupil: Unilateral or bilateral irregularly
dilated pupil that constricts slowly and unevenly to
light. Normal vision. Adie (Tonic) Pupil.
Dorsal midbrain (Parinaud) syndrome: Bilateral,
normal to large pupils. Accompanied by
convergence retraction nystagmus and supranuclear
upgaze palsy. Adie (Tonic) Pupil and Convergence-
retraction in Nystagmus.

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THANK YOU

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