CONTENTS

Introduction
Definitions Types of perimetry Kinetic Static Methods of perimetry Manual - Goldmann Automated - Humphrey HVF programs (screenings and threshold tests) Examination techniques Instructions Errors possible Interpretation Single field analysis Progression analysis Innovations Practical tips Quiz

DEFINITIONS VISUAL FIELD: Visual field is that portion of space in which objects are simultaneously visible to the steadily fixating eye PERIMETRY: The technique of determining the either the central or peripheral field of vision ISOPTER: Isopter for a given stimulus size is obtained by joining points with equal areas of sensitivities. KINETIC PERIMETER: Presentation of a moving stimulus of known intensity, size, color and speed from a non-seeing area to a seeing area until it can be perceived STATIC PERIMETER: It involves presentation of a stimulus of varying luminance in a given area, keeping the size of the stimulus a constant. Hence it is also differential light sensitivity THRESHOLD: Threshold sensitivity is the characteristic of a stimulus that is perceived 50% of the time SUPRA THRESHOLD STIMULUS: Stimuli that are brighter (more intense) than the threshold stimulus are supra threshold (or supraliminal stimuli)
INFRATHRESHOLD STIMULUS: Stimuli that are weaker (less intense) than the

threshold stimulus are infra threshold (or subliminal stimuli) APOSTILBS (asb): The term apostilbs relates to luminance of a given test target being projected on to the interior of the white bowl. DECIBELS (dB): The term decibel is a relative value, which expresses the attenuation from maximum intensity of 10,000 asb. SCOTOMA: An area of partial or absolute loss of perception within an area of normal or relatively normal visual field. RELATIVE: An area of partial loss of perception within which some targets can be seen and others cannot be visualized ABSOLUTE: Total loss of perception where even the brightest and biggest cannot be perceived

Visual field is compared to a hill of vision surrounded by a sea of blindness. The hill of vision has a narrow peak at its center representing the fovea, the area of greatest resolution. The field of vision decreases gradually as the hill slopes down due to decrease in contrast sensitivity. In the Visual field, 15 degrees temporal and 2 degrees inferior to the fixation lies the area of physiological scotomas representing the OPTIC DISC also called the blind spot of Mariotte. The blind spot measures 6 degrees horizontally and 9 degrees vertically and is an example of absolute scotoma.

Traquiars Hill of vision

Fovea-The HILL Optic Disc / Blind spot

Sensitivity decreases as the hill slopes down

Traquiars Hill of vision surrounded by sea of blindness

BOUNDARIES OF VISUAL FIELD

The boundaries of field of vision measured from the point of fixation are as follows

Monocular Temporal: 100 degrees Inferior- 75 degrees Superior-60 degrees Nasal: 60 degrees

Binocular: 120 degrees

CORRESPONDENCE OF RETINA AND THE VISUAL FIELD

Every point in the retina corresponds to a certain direction in the visual field. The fovea corresponds to central vision (The yellow line) and the points in the peripheral retina correspond to peripheral visual field. The image formed by the optics of the eye is upside down and backwards thus 0

The objects that falls on the nasal retina is perceived in the temporal visual field and vice-versa Points on the superior retina correspond to objects in inferior visual field and vice-versa. The black spot also called the Blind Spot Of Mariotte is the area of absolute scotoma , which represents the optic disc.
1

The field of vision for each eye is normal if all parts of the visual pathway are intact and functioning normal .The field of vision is abnormal if one or more lesions are present in some part of visual pathway in which case on or more corresponding visual field defects are found.

INDICATIONS FOR VISUAL FIELD TESTING

Visual field testing can lead to early detection and treatment of a disease. The purpose of visual field testing is to provide information critical to Diagnosing ocular diseases especially glaucoma Evaluating the neurological and retinal diseases Monitoring the progress of ocular and neurological diseases

TYPES OF PERIMETRY
Kinetic perimetry Static perimetry

KINETIC KINETIC TARGET

STATIC

Constant luminance, Constant size and speed and color position but intensity varied Qualitative Quantitative

TYPE SENSITIVITY

Sensitive to large & Sensitive to small and insensitive to shallow, flat areas of defect but small areas of defect Insensitive to large areas

KINETIC PERIMETRY
Two-dimensional assessment of the boundary of the hill of vision. Presentation of a moving stimulus of known intensity, color and speed from a non-seeing area to a seeing area until it has been perceived. The stimulus is moved at a steady speed along a series of meridians and the point of perception is recorded on a chart. ISOPTER for a particular stimulus size is plotted by joining the points with same sensitivities. Using different stimulus sizes a contour map of visual field with different isopters are plotted to check for consistency of depression (if any) in the field of vision

Figure showing isopter plotted with different stimulus sizes. The fovea (Represented as yellow and red colour in the picture) has the highest sensitivity and the sensitivity decreases with eccentricity (from orange to black in the above picture). Kinetic perimetry can be performed by Simple confrontation, Tangent screen, Goldman perimeter Confrontation techniques USES Useful as the only type of examination that is feasible for patients who cannot perform well on the perimeter To screen for the presence of a defect. To determine approximately the type and extent of a visual field defect to be expected on perimetry. Basic confrontation techniques used are Finger-counting method Comparison method

FINGER-COUNTING METHOD SCREENING PROCEDURE Each eye tested separately and the fellow non- tested eye should be occluded with the patients palm The patient should be asked to fixate on the examiners face (usually the nose) and report how many fingers the examiner holds up in the peripheral field The examiner closes his right eye when testing the patients left eye and vice versa Each quadrant is tested separately by placing the examiners hand 3 or 4 feet away from the patient, about 45 degrees from the fixation\ If the fingers cannot be counted in a given quadrant at 45 degrees, then the target can be moved from a non-seeing area to seeing area until the object can be seen by the patient. For example a Bitemporal Hemianopic field defect should be illustrated as below OD NASAL BRIDGE OS

COLOR COMPARISON: o Red colored targets such as bottle cap can be presented in the temporal and nasal fields of the patient to check for color desaturation in patients with early optic chiasm compression.

STATIC PERIMETRY
Most Commonly used Office perimetry Static perimetry is a three-dimensional assessment of the height of a predetermined area of a hill of vision. It involves presentation of a stimulus of varying luminance in the same position keeping the size of the stimulus a constant. Hence it is also differential light sensitivity. Visibility of a stimulus in static perimetry depends on Intensity, Background against which it is presented, Color Movement Length of time it is presented. When the stimulus is not visible then in case of automated static perimetry, luminous intensity is adjusted. Threshold When a stimulus is within a region of uncertain visibility (between non seen and seen points) intensity can be adjusted to a level at which the patient responds to 50% of the time

Frequency of Seeing Curve

100

Percentage of times seen

75

Threshold Sensitivity

50

25

Increasing intensity

FIGURE: Graph that indicates the percentage frequency with the intensity at which the stimulus is seen.

Thus Threshold sensitivity is the characteristic of a stimulus that is perceived 50% of the time. In standard bracketing presentation it is estimated as the weakest static stimuli seen with standard background intensity, duration of stimulus presentation and of defined stimulus size and color SUPRA THRESHOLD STIMULUS: Stimuli that are brighter (more intense) than the threshold stimulus are supra threshold (or supraliminal stimuli) INFRATHRESHOLD STIMULUS: Stimuli that are weaker (less intense) than the threshold stimulus are infra threshold (or subliminal stimuli) UNITS OF LIGHT INTENSITY
APOSTILBS (asb): The term apostilbs relates to luminance of

a given test target being projected on to the interior of the white bowl. DECIBELS (dB): The term decibel is a relative value, which expresses the attenuation from maximum intensity of 10,000 asb. They are inversely proportional units 10,000 ASB (Highest intensity) = 0 dB 1000 ASB = 10 dB 100 ASB = 20 dB 10 ASB = 30 dB

No direct conversion is available between apostilbs and decibels. Conversion involves use of logarithmic calculation. The intensity range of the Humphrey Field Analyzer is from 10,000 to 0.1 apostilbs (asb). 10,000 apostilbs is the target with highest intensity, therefore; if a patient does not respond to even that intensity , then the scotoma is considered to be absolute or blind Intensity in Goldmann perimetry and octopus machines is 1000 abs.

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METHODS OF PERIMETRY
Manual (e.g. Goldmann perimeter) Automated (e.g. Humphrey field analyzer) Differences Between Manual and Automated Perimetry
MANUAL PERIMETER AUTOMATED PERIMETER

Lack of reproducibility of the Excellent reproducibility patients test Presentation of stimulus No bias since testing is automated manually might give rise to examiner bias Analysis of defect progression Progression analysis, overview of difficult previous tests, change probability analysis available Standard testing only available. Custom tests can be done depending on the patients requirement. Less dependant on the examiner.

Examiner dependant

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GOLDMANN PERIMETER (Manual perimeter)

Goldmann manual perimeter was considered as a gold standard for perimetry testing years ago. It is a hemi-spherical projection system with a self-illuminated, projection perimeter. The systems consists of the following ILLUMINATION SYSTEM
NITRA LAMP illuminates a circumscribed peripheral area above and inside

the bowl.
BACKGROUND INTENSITY: The background intensity is maintained at 31.5

abs (apostils).
RADIUS OF THE BOWL: 300 mm and is inner surface painted matte white

PROJECTION SYSTEM: TARGET: Spherical projection system with the light for the perimeter target sent by a condenser through a hollow arm that contains the projection system. 1 MOVEMENT: The movement of the projection arm is produced by pantograph controlled by a handle that slides on a vertical plate of opal glass illuminated from behind (on the back of the perimeter). This plate carries the recording chart. Each position of the handle corresponds exactly with the position of the spot of light on the hemisphere. By moving the handle across the chart the visual field may be examined for 95 degrees on each side of fixation.
0

OBSERVATION SYSTEM:
A telescope through the back of the hemisphere allows for constant

observation and control of patients eye.

GOLDMANN PERIMETER

Goldmann target characteristics:

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 In standard Goldmann nomenclature, the target size and intensity are

indicated by a roman numeral (from 0 to V), an Arabic numeral (from 1 to 4) and a lower case letter (a through e) Thus a Goldmann target would be designated as I2e, V4e etc I2-E Size Intensity The standard target sizes are expressed in square millimeters and the size increases from 0 through five.
0

Roman numeral 0 I II III IV V

Size in millimeters 0.062 mm2 0.25 mm2 1 mm2 4 mm2 16 mm2 64 mm2

TARGET INTENSITY: 0 The Arabic numeral following the Roman numeral indicates the relative intensity of the light projected. 1 2 Beginning with numeral 1, each additional numeral indicates a light that is 3.15 times brighter than the predecessor. INTENSITY OF NUMERAL 2 3 .15 * INTENSITY OF STIMULUS 1

The small letter following the roman and Arabic numeral indicates a

minor filter. Each minor filter adjusts the luminance by 0.1 log units. o Filter a is the darkest, and the stimulus intensity increases in 0.1 log unit for each letter up to e. Static testing with Goldmann becomes more time consuming when performed manually. Many researchers claim static testing superior to the kinetic method for quantification of defects. The advancement in technology has evolved into a more precise measuring tool (automated perimeter) for yielding highly repeatable results with ease of performance.

HUMPHREY VISUAL FIELD ANALYZER (Automated Perimetry)

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HUMPHREY AUTOMATED PERIMETRY

The Humphrey visual field analyzer (HFA) model I (HFA-1) was introduced in 1984.It was soon replaced by HFA 2 in 1984, which has been used most commonly among practicing clinicians. HARDWARE: Consists of a rectangular box approximately 2 ft wide by 2 ft tall and 1 ft deep. The machine is contained within a box with an aspherical bowl with a central radius of 30 cms. The height of the machine can be adjusted according to the patients convenience. The patient is positioned facing the bowl with a forehead strap and an adjustable chin rest for alignment and proper positioning. Six motors control the projection of stimulus into the bowl. Manual monitoring of patients fixation is made possible with a video camera. o The camera displays the image of the patients eyes as a small inset on the instruments monitor. o The video monitor has a reticule to be coincided with patients pupil and has a provision for adjusting the brightness level. Fixation is also monitored by a gaze tacking unit that can also detect when a patients head moves backward (vertex monitoring). HFA-2 employs a Motorola 68020 microprocessor with 4 megabytes of random access memory. Storage of test data is made possible with a 3 -in floppy drive and the hard drive. Faster tape backs up to prevent loss of data in case of hard drive failure.

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SOFTWARE:
The HFA-2 software has following components Testing strategies and programs Reliability catch trials Statistical interpretation.

TEST STRATEGY
The various testing strategies available in static perimetry are o Screening program o Threshold program

Screening program:
They are supra-threshold test to determine whether threshold visual sensitivity is above or below the chosen criterion. Such a test may detect an abnormality and outline its location and extent but does not quantify its depth and thus can be used mainly for screening purposes. ADVANTAGES: To detect abnormality (screening) To characterize the topographical nature of an abnormality and To quantify the boundary of the visual field

COMMON SCREENING PROGRAM

TEST PROGRAM AREA AND POINTS TESTED
300 AND 76 POINTS

APPLICATION

CENTRAL 76

GLAUCOMA AND NEUROLOGICAL ASSESMENT

FULL FIELD 120

600 AND 120 POINTS

GENERAL, GLAUCOMA AND NEUROLOGICAL ASSESMENT

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THRESHOLD PROGRAMS
TEST PROGRAM AREA, POINTS AND SPACING OF TEST
300 / 76 POINTS 60 SPACING 240/ 54 POINTS 60 SPACING 100/ 68 POINTS 20SPACING 50/ 16 POINTS 20 SPACING

APPLICATION

CENTRAL 30-2

GLAUCOMA NEUROLOGICAL GLAUCOMA NEUROLOGICAL

CENTRAL 24-2

10-2

ADVANCED GLAUCOMA

MACULA

MACULAR ASSESMENT

Threshold programs most frequently used in glaucoma/neurological diagnosis concentrate on central 30 degrees or 24 degrees of the visual field at location 6 degrees apart. Most disease affects this central region and early-localized defects rarely are focal in nature that they would escape detection between tested points that are 6 degrees apart. A 24 degrees field is more preferred for a patient with glaucoma because The number of points tested in case of a 30 degree field is 76 points whereas 24 degrees field-tests only 54 points. Less time consuming and causes less fatigue to the patient than a 30 degree field due fewer testing points A 30-degree field is more preferred for General or Neurological assessment because of the greater number of points tested. In case of severe course of disease, different pattern of points

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 Central 10 degrees with 2 degrees spacing or for evaluating the threat to

fixation. Performed in cases where 30-2/24-2 field show severely depressed points and large areas of absolute defects leaving only a small island of vision centrally /temporally. Macular threshold testing central 5 degrees of visual field can be performed to know the macular status.

Visual field testing

For glaucoma cases Start with a 24-2 field with SITA standard (with size III stimuli) If the visual acuity is less or when the field shows advanced absolute defects then two programs can be done Increase the stimulus size to V. This strategy will add about 10 dB to each point thus converting absolute defects to single/double digits threshold values. Test only the central 10 degrees of visual field (10-2 size III stimuli). Tests 68 points spaced 2 degrees apart. Closer spacing allows detection and definition of scotomas threatening fixation In a patient with severe end stage glaucoma even 10-2 (with size III stimuli) might show remnant sensitivity. Then field should be tested with a bigger target size (size V). NOTE: SITA strategies work only with size III stimulus. When testing needs to be done in other stimulus sizes then Full threshold or Fast Pac algorithm has to be used. When 24-2 size V is done then do not do a 10- 2 with size III as the field might not yield useful information STATPAC analysis is not available for Size V stimuli. Try to test the visual field with size III stimuli as much as possible (provided it gives proper information about the field)

For Neurological cases

Visual field testing is usually done to establish the pattern of defect. Hence a wider and faster strategy will provide useful information Perform a 30-2 testing with SITA standard / SITA Fast (Size III stimuli) When testing with size III stimuli shows advance field loss and fails to give a clear pattern then testing with size V stimuli has to be carried out. If visual field shows involvement of superio-temporal quadrant then a full field-testing will be useful to find the extent of defect beyond the central field.
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Threshold algorithms
Most perimeters have four algorithms for determination of threshold sensitivity at each test location Original Full-Threshold test Fastpac Swedish interactive threshold algorithm (SITA) standard SITA fast

FULL THRESHOLD TESTING: Established Gold standard and was the most commonly used standard program in the static threshold determination at locations 6 degree apart within the central 30/24 degrees with the grid spanning the horizontal and vertical meridians To begin a threshold procedure a stimulus brighter than predicted estimated Hill of vision is presented and a classic 4-2 double staircase technique is performed for determining the threshold value.

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STAIRCASE PROCEDURE Stimulus of pre-selected intensity presented

If patient sees stimulus

If the patient does not respond

Then

Then

Stimulus of 4 dB lesser intensity is presented till the patient does not respond

Stimulus of 4 dB higher intensity is presented till the patient responds

Then

Then

Stimulus brightened by 2 dB until patient responds

Stimulus dimmed by 2 dB until patient responds

Last responded stimulus taken as threshold value

The last stimulus responded is recorded as the threshold value

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 The test begins with the central foveal threshold testing with the patient gazing at the center of the fixation diamond projected about 10 degrees below the normal fixation spot, which occupies the center of the bowl The testing for central and peripheral locations begins with the initialization of four central points, one in each quadrant. With the same bracketing or staircase strategy the differential light sensitivity is tested

dB
(dB)

dB
(dB)

dB
(dB)

dB
(dB)

Note: Figure shows the first four points tested in a full threshold testing. Values within brackets indicate points that are double tested to calculate short term fluctuation

The values obtained are used to estimate the starting points of other test locations within the same quadrant In full-threshold algorithm the sensitivity is determined doubly at 10 preselected points, which is used to measure the measurement error or the shortterm fluctuation (SF). Fastpac: The Fastpac strategy changes stimulus intensity in 3 steps instead of 4 dB steps, either stronger or weaker depending on the initial patient response. When sequence crosses threshold the testing stops without reversing direction in smaller steps saving time (only single crossing over rather than double crossing when compared with full threshold). Threshold recorded as the last seen stimulus in the sequence Fastpac test times are approximately 25 to 30 % lesser those of full threshold. Few subtle or shallow defects might get missed due to single cross over and subsequent compromise of accurate threshold determination.

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SWEDISH INTERACTIVE THRESHOLD ALGORITHM (SITA) The strategy permits a more time efficient estimation of threshold than the non-interactive staircase strategies. Two versions of SITA have been produced till date. SITA Standard, which runs in about half the time of standard full threshold algorithm with the same test-retest reproducibility SITA FAST, which runs in about half the time of Fastpac with the same reproducibility as the Fastpac. Factors contributing time saving efficiencies of SITA, primarily include 0 ACCURATE CHOICE OF STIMULI SITA starts with prior probability models of normal and abnormal visual fields. (The model is based on age corrected values in the normal and the
glaucomatous population, frequency of seeing curves around threshold values and correlations between adjacent test points.)

It integrates the results of more neighboring points and thus starts the examination with a better estimate of expected threshold thus reducing time. Makes complete use of available information and thus reducing the test time to achieve a given level of stability. 1 2 3 SITA KNOWS WHEN TO QUIT (GOOD INFORMATION INDEX) SITA takes advantage of its information index to analyze the responses at all points Testing at a point ceases when the pre-determined levels of testing certainty is reached and no further testing is carried out thus reducing testing time. The testing time is made shorter when reliably consistent responses are given and extends when there is uncertainty. The limit that is selected is the major difference between SITA STD and SITA FAST. In SITA STD testing does not stop unless there has been at least one cross over from seeing to non-seeing (or vice versa), whereas SITA fast is not always required to cross it

4 REACTION TIME 0 The pacing of the test is adjusted with the patients behavior and capabilities in performing the test .For quick responders the pace of testing is quicker and for slow responders extra time is given to respond.

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FINAL CALCULATION

SITA re-computes all the points after testing has been completed a more precise estimate of all threshold values are made. It includes re evaluation of the time interval to accept responses and thereby determines which responses were likely false answers and which are to be used to determine the final Bayesian probability function. 6 FEWER CATCH TRIALS Final calculation also produces calculation of the rate of false responses thus producing better estimates of false positive and false negative responses and saving time but reducing the number of catch trials. The overall effect of these efficiency improvements reduce the testing time for SITA standard and fast strategies by 50% relative to the strategies they replace, without the loss of diagnostic information After the selection of testing algorithm and strategy, other test parameters required for the testing are carefully chosen. For both screening and threshold testing, the parameters can affect the total test time and the precision to which the measurement are made. The important parameters include: STIMULUS SIZES Stimulus sizes I, II, III, IV and V are available in the HFA. Stimulus size III is the most commonly used. A larger size (Size V) is used when the patient is not able to perceive the smaller stimulus size. FIXATION TARGET CENTRAL: Most commonly used target which has a central yellow light on which the patient fixates during the test. Small diamond: The small diamond is located below the central target, and should be used when patient cannot see the central fixation target (e.g. macular degeneration). The patient should look in between the four lights. Large diamond: The large diamond is located below the central target and is useful for patients with central scotoma who cannot see either the central fixation light or the small diamond

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 FOVEAL THRESHOLD 0 Foveal threshold is by default switched OFF in HFA. The parameter has to be switched ON to determine the foveal threshold of the patient. FLUCTUATION 0 When turned ON, threshold for ten pre-selected points are re-tested to determine the
variability of the patients responses Threshold values for the re-tested points appear in parentheses directly below the first testing value. This is used in determining the Short term fluctuation and thereby the CPSD. Note: Fluctuation is available only with FULL THRESHOLD STRATEGY.

BLUE-YELLOW 0 Blue on yellow background is selected to perform Short Wavelength Automated Perimetry (SWAP). 1 This is used in patients Glaucoma suspects Ocular hypertensives and Glaucoma patients who show normal W-W field
B-Y perimetry is currently available only with Full threshold strategy and hence is a time consuming test. It should be performed with a large stimulus size (Size V) to facilitate perception of stimulus size. Fluctuation should be turned on to obtain Short term fluctuation (SF) and CPSD. After selection of the required parameters the testing for estimating the field of vision begins. Testing for the foveal threshold is done followed by the testing for peripheral field.

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PATIENT INSTRUCTIONS
The patient has to be explained about the importance and necessity of the test to achieve complete compliance. The patient should be seated comfortably in front of the instrument as improper height would lead to early fatigue and thus would not yield reliable results. FOR FOVEAL TESTING Foveal threshold is switched on for all threshold tests before starting to test the visual field. Once the foveal threshold option is selected a small diamond fixation target (four lights, yellow in color) will be automatically illuminated. The patient should be instructed that a light (white for white on white perimetry and blue for blue on yellow perimetry) of varying brightness (ranging from very dim to bright) would appear in the center of the yellow colored lights. The patient is expected to respond by pressing the response button whenever he sees the light. The patient should be informed that the light (stimulus) will stay only for few seconds He should also be informed that the stimulus will be appearing many times and he should be responding as and when he sees the light Once the Foveal threshold test is completed the examiner has to correlate the foveal threshold value with the patients vision. Foveal threshold value may vary from person to person: it should approximately correlate with the vision as given

NOTE:
Threshold value decrease with age, always consider age, physical fitness, activity of the patient before you repeat foveal threshold. If Foveal threshold remains low against the corresponding vision, even on repetition, then continue with peripheral threshold. Value of foveal threshold increases for size V stimulus.

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FOR PERIPHERAL FIELD TESTING He should be instructed to look only at the fixed yellow light (fixation target most commonly used for peripheral testing). A diamond target can be used in cases where involvement of central vision is suspected to stabilize fixation. He should be informed that lights would flash one at a time from any side of the bowl area and that some lights will be bright and others dim. He should press the response button whenever he sees the light. The patient should be informed that he is not expected to move his eyes to either search for, or to look at the light thats flashing in the sides. He should be notified that he would not be seeing all the presentations and that the test is designed so that they will be seeing fewer than half of them. The patient may blink his eyes when he responds to the light. If the patient needs rest he can be informed that he can hold the button down (in pressed state) and that the test would be paused until he releases the switch back to its own state. Once the peripheral testing is started the examiner has to monitor the patients performance during the test. Careful monitoring of the patient especially during the first few minutes of testing would give the examiner an idea about the patients understanding of the test .This will enable the examiner to explain to the patient any kind of error that he is rendering and will avoid unnecessary test repetitions. The patients position (head and chin position) should be monitored throughout the test. Reliability criterion namely fixation losses, false positive and false negative errors should be monitored and instructions respective to the nature of error must be given to ensure good performance. The raw threshold values that appear on the monitor should roughly correlate with the fundus finding (diagnosis) of the patient. If the values do not correlate then it is likely that the patient has not understood the test.

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ERRORS POSSIBLE DURING VISUAL FIELD TESTING Improper patient instruction including language difficulties

1st time 2 nd time

Fundus of this patient showed a 0.5: 1 CDR with normal neural rim. Initial testing (report to the left) shows a dense inferior altitudinal defect not corresponding with the fundus picture. Instructions were repeated in patients own language and subsequently it was found that the field of vision was normal, indicating the necessity of comprehensible instructions.

Learning curves

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The figure on the top-left shows a nasal hemianopic defect which did not correlate with the fundus evaluation. Instructions were repeated and the patient was given a demostartion as to how the stimulus is being presented. On repeated testing the performance improved and the field was normal subsequently.

Wrong eye selected

Wrong eye selected. selected. Previous exam with correct selection of eye 27

 Wrong eye occluded for testing (or wrong eye selected) The previous field report of the patient shows a biarcuate defect (with correct eye selection ) The other field report on the left shows that the4 left eye of the patient is selected but the grey scale clearly illustrates the presence of blind spot in the nasal region, which suggests that the wrong eye(left eye) has been selected but the correct eye(right eye) has been occluded.

Improper positioning of trial lens

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 Refractive error of this patient is only +3.75 DS which will not usually cause an artifact when the trial lens holder is placed close to the patients eyes. In this case the trial lens holder was placed far away from the patients eye which causing a RIM artifact.

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Eyelid artifacts
Narrow palpebral fissure before taping After taping

Vertical Palpebral fissure height of the patient was only 6 mm. The small PF resulted in superior lid artifacts. On repeating the test after taping the lids apart with a medi-tape the artifacts vanished

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 Cylindrical lens artifact Picture above shows the full aperture cylindrical trial lens which is commonly used at clinics in India. These lenses produce an artifact corresponding to the axis of the cylinder due to the increase in vertex distance. Figure to the left shows a field report with cylindrical lens induced artifact caused due to increased distance between the lens correction and the patients eyes. Figure below shows absence of the artifact when the vertex distance was decreased...

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 Improper head positioning

Head taken back from the actual position causing a dense artifact inferiorly.

Poor patient compliance

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o Fatigued patient

High false negative error due to fatigue effect Field report showing a cloverleaf pattern. o High false positive responses
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Trigger happy patient presenting with white scotomas GHT abnormally high sensitivity.

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IMPROPER TRIAL LENS CORRECTION Reliable visual field performance. Correction to be placed: +3.25/-5.50 DC*100 Correction placed : +3.00DS Field Interpretation: Generalized reduction of sensitivity +Inferior arcuate and few superior nasal defects.

INITIAL TESTING

ON REPEATING HVF

On repeating the test with accurate trial lens correction the generalized reduction in the visual field report vanished, number of points in the pattern deviation plot decreased and the mean deviation improved.

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Once the visual field testing is done the perimeter calculates the raw data and compares the patients threshold values with the age matched normative data (for threshold testing). The analysis of the patients field can be performed in the following ways: Single field analysis Over-view Change analysis Three-in-one Glaucoma change probability analysis (only for full threshold testing)

Note: Statistical analysis is available only with size III stimulus because normative database is available only for the same. For testing with size V stimuli only three-in one print option, which consists of raw data, Grey scale, and defect depth is available.

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THE SINGLE FIELD PRINTOUT

Standard single field presents the raw test results of a single 30-2,24-2, 10-2 threshold tests along with a statistical analysis of the results relative to agecorrected normal data. The different information on the printout is divided into 7 zones.

2 3 4

5 6 7 8

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ZONE 1 Basic identification of the patient and the test ZONE2 Indicators of test reliability o Fixation losses o False positive responses o False negative responses ZONE 3 Raw unprocessed data (threshold sensitivity in decibels) ZONE 4 Gray scale ZONE 5 Deviations of measured sensitivity from normal (Total deviation) ZONE 6 Deviation from normal after adjustment for overall reduction of sensitivity (Pattern deviation) ZONE 7 Overall indices of normality (Global indices) ZONE 8 Plain language analysis (Glaucoma Hemi-field Testing)

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ZONE 1

Basic identification of the patient and the test, which includes o Patients name and ID number for the purpose of identification during future testing. o Date of birth: To calculate patients age and for comparison with age matched normative data base (STATPAC) o Eye tested o Fixation monitor: Gaze tracker/Blind spot or both o Fixation target: Central, Large diamond, Small diamond o Pupil size: Important to be noted as a change in pupil size might affect test results.

PUPIL DIAMETER

o Visual acuity: For correlation purposes as gross constriction if fields might be due to low visual acuity. o Test program (30-2/24-2 or 10-2) and strategy (full threshold or SITA) used
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ZONE 2
INDICATORS OF RELIABILITY Three types of reliability parameters are generated.

To estimate stability of patients gaze (to find the number of fixation losses) To estimate patients tendency to make false positive responses and To estimate those intended to make false negative responses

FIXATION MONITORS
Fixation is monitored by 1. Blind spot monitor, 2. Gaze tracking, 3. Perimetrist observation

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Heijl-krakau blind spot monitor can be use to find the fixation losses during the test. In this method moderately bright stimuli are presented periodically at the expected location of the physiological blind spot the location of which is determined during initial testing. Assumption is that if the patient responds to the stimulus then there must have been a gaze error large enough to move a seeing retina into the location of the stimulus. Magnitude of such an error should be half the diameter of the blind spot (i.e.). at least three degrees. Approximately 5%of the stimulus presentation through out the test are being used for fixation monitoring with Heijl- Krakau method
POSSIBLE REASONS FOR FIXATION LOSSES.

Head tilt, especially that which occurs if the head drifts slowly from a perfectly vertical position Wrongly located blind spot position. Could arise when the wrong eye is occluded. Chin /Head position is improper. Patient excessively moves his eyes during initial testing, which does not allow the blind spot to be located appropriately. High false positive responses wherein the patient is trigger-happy and does not allow estimation of blind spot. Occasionally the optic disc of the patient is smaller than the normal and hence the active retina comes into the presumed blind spot causing fixation losses With the blind spot checking method the fixation loss rate is recorded on the print out a the ratio of the number of times the patient responded to the blind spot stimulus divided by the total number of presentation

Fixation loss: Number of times the patient responded to stimulus / total number of
presentations

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 Double X (XX) is printed next to the fixation loss rate whenever ratio exceeds 20%

High fixation losses indicate that the patient did not fixate well during the test, or that the blind spot was incorrectly located.

GAZE MONITOR
Available with recent models of 750 It uses image analysis methods to locate the center of the pupil and the location of the corneal reflection of an infrared source

Working of the gaze tracker

Gaze straight ahead

Corneal center near center of pupil

The picture above shows the position of the corneal reflex when the patient is maintaining the straight-ahead position.

42

Gaze to right

Corneal reflex displaced from the center from the pupil

This picture shows the deviation of the patients eye from straight-ahead position to right gaze. The reflex is displaced from its initial position in the pupil and the deviation that the patient made is marked in a graph as UPWARD DEFLECTIONS DOWNWARD DEFLECTIONS indicate absent reflexes usually during blinking

INITIALIZING GAZE TRACKING Gaze tracking can be selected only at the beginning of a test, although it may be turned off at any time during the test To initialize gaze-tracking Position the patients eye until it is located in the center of the video eye monitor Instruct the patient to look at the fixation target, trying not to blink, for a few seconds and until the examiner tells them the process is over. Patients with droopy eye-lids should keep their eyes as wide open as possible With successful initialization of gaze two other features namely head tracking and vertex monitoring are being initialized. These
43

features work to keep the patients eyes positioned in the center of the trial lens. Gaze tracking may not work well in the following situations Very small pupils and droopy eyelids High powered trial lenses Excessive eye movements Cloudy media After the test has begun, you may wish to re-initialize Gaze tracking if: The patient shifted eye position dramatically The Gaze graph indicates poor fixation even though the patient was fixating in a steady manner Many downward markings show on the Gaze graph indicating the Gaze system was having trouble detecting the patients head too far in the wrong direction The vertex monitor was sounding often even with good head positioning Press the FIXATION button on the test screen and press the RE-TRY to INTIALIZE GAZE button to reset Gaze tracking. If Gaze tracking does not initialize successfully, head Tracking, pupil size measurement, and vertex monitoring cannot be utilized. Blind spot monitoring and visual observation are still available to assess the reliability of the patient results in these situations. ADVANTAGES: Fixation of the patient checked during 100%of stimulus presentations, rather than 5%as with Heijl-krakau method No separate time devoted to fixation check presentation, thus saving 5%of testing time allotted for blind spot check FALSE POSITIVE RESPONSES The false positive error rate is the frequency with which the patient presses the button when no stimulus is presented The number of erroneous responses per catch trial is given as ratio (as in full threshold testing algorithm) or the percentage (as in SITA testing strategy) When the responses exceed 33% of presentations then a XX appears on the screen and on the printout. A high false positive score indicates that the patient score indicates that the patient is Trigger-Happy

44

FALSE NEGATIVE RESPONSES False negative error is the frequency with which the patient fails to press the response button, when a visible stimulus is presented. When the responses exceed 33% of presentations then a XX appears on the screen and on the printout and a warning message low patient reliability appears above then GHT. High false negative scores might indicate fatigue or inattentive patient

ZONE 3 - RAW TEST RESULTS

THRESHOLD SENSITIVITY VALUES: Decibels threshold sensitivity values are displaced as a map (sensitivity value table), except that the sensitivity of the fovea is listed over the side along with the reliability parameters.

45

ZONE -4 INTERPOLATED GRAY SCALE:

To develop a grey scale printout, interpolated threshold sensitivity values are assigned to locations between the test points and the threshold sensitivities and are combined groups 5 db in width, so that the range from 1 to 40 decibel is assigned to eight levels of grey. The grey scale is another way of displaying raw threshold data and is not statistical or normative analysis.

ZONE-5 TOTAL DEVIATION (Deviation From Normal Values Of Age)

TOTAL DEVIATION = (PATIENT'S RESPONSE) - (EXPECTED NORMAL) These are both represented in decibels and the difference between the two result in either a positive or negative decibel value. Positive means the patient performed above the expected and a negative means they performed that number of decibels below the expected.

46

ZONE-6 PATTERN DEVIATION

Pattern deviation is the deviation from normal after adjustments for overall sensitivity. The function of the pattern deviation plot is to expose localized defects that may be masked by either a generalized depression or an elevation of the hill of vision. This is done by making an adjustment of the threshold values according to general height(GH) of the visual field.
PATTERN DEVIATION = (TOTAL DEVIATION) + (OVERALL SENSITIVITY CHANGES)

47

ZONE-7 GLOBAL INDICES

1.) Mean Deviation or Defect (MD) - The (MD) is the mean difference in decibels between the "normal" expected hill of vision and the patient's hill of vision. If the deviation is significantly outside the norms, a P value will be given. Example: P< 0.5% means that less than 0.5% of the normal population showed a (MD) larger than the value found for this test. This index is a measure of overall depression, elevation of the field or significantly deep losses in one part of the field and not in others. 2.) Pattern Standard Deviation (PSD) - This is a measurement of the degree, which the shape of the patient's measured field or hill of vision departs from the "NORMAL" age-corrected reference field model. The value is expressed in decibels and any value of 2dB or greater will have a (P) value next to it indicating the significance of the deviation. 3.) Short-Term Fluctuation (SF) - It is an index of the consistency of the patients responses during the field-testing. This value is obtained when ten (10) pre-selected points are tested twice and the difference, in decibels, of the patients responses is compared.

48

2 8 2 9 2 9 2 1 2 8 2 9 2 9 2 9 3 1 3 3 3 0 3 2

2 8 3 0 3 0 3 2 3 2

2 6 2 4 2 9 3 1 3 2

2 6 2 9 3 0 2 7 2 9 2 8 2 9 2 6 2 9 2 8 2 6 2 7

(31 )

(30 )

3 3 (32 ) 3 2

3 1 (33 ) 3 3

2 8 2 7

2 9 2 9 2 0

3 2 3 1 2 9(30 ) 2 5

3 2 3 2 3 1 2 8 2 5

(32 )

3 2(31 ) 3 2 3 0 2 9 2 5

3 4 (33 ) 3 2 3 2 2 9 2 6

3 4 3 3 3 0 2 7 2 5 3 2

2 8 3 0 2 3

2 7 2 9

(30 )

2 9(31 ) 2 8

4.) Corrected Pattern Standard Deviation (CPSD) This is a calculated measurement in decibels of how much the total shape of the patient's hill of vision deviates from the shape of the "NORMAL" hill of vision for the patient's age, after being corrected for intra-test variability. In calculating the (CPSD) the STATPAC (software that performs a series a statistical calculations on visual field) attempts to determine if the irregularities in the hill of vision are real by removing the short-term fluctuation (SF), which may mask a relative scotomas

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ZONE 8- PLAIN LANGUAGE ANALYSIS (GHT)

The Humphrey glaucoma hemi-field test (GHT) gives the plain language analysis of visual field result, assuming glaucoma is the diagnosis considered. The analysis takes onto account groups along the path of nerve fiber bundles. In the GHT five zones in the upper field are compared with five zones in mirror image locations in the lower field A score is assigned to each zone based on the percentile deviations in the pattern deviation plot of the points in the zone. A comparison of each upper zone is made with the corresponding lower zone, and the difference in scores between the upper an lower zones is compared with significance limits taken from a database of normal subjects.

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Five possible messages may appear as the summary result of the GHT. 0 WITHIN NORMAL LIMITS This message appears if none of the four conditions are met. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
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37 BORDERLINE 38 In comparing the upper zones with the lower zones, at least one zone pair difference exceeds that value found in 97% of normal individuals.

52

39 GENERAL REDUCTION OF SENSITIVITY This message appears only if neither of the conditions for the outside normal limits message is met, but the general height calculation shows the best part of the field to be depressed to a degree that occurs in less than 0.5%of the normal population.

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40 OUTSIDE NORMAL LIMITS: This means that one of two conditions have been met (1) when the scores in the upper zone are compared with those of the lower zones, at least one sector pairs score difference must exceed that found in 99%of the normal population Or (2) the individual zone scores in both members of any zone pair exceed that found in 99.5%of the normal individuals

41 42 43 44 45 46 47 48 49 ABNORMALLY HIGH SENSITIVITY The general height calculation shows the overall sensitivity in the best part of the file to be higher than that found in 99.5% of the population. Here the comparisons of upper and lower zone are not made.

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50 51 52 53 54 55 56 57 58

INTERPRETATION OF SINGLE FIELD

Visual field examinations are performed with diagnostic goal in mind. Before approaching the decision of interpretation confounding factors and artifacts of the examination should be evaluated. The visual field reports have to be correlated clinically to check their correspondence with the ocular findings.

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 One important factor that has a major impact on interpretation of patients field is the reliability of the test result. Unreliable fields can result in a defect being missed falsely or could result in an artifact, produced by an imprecise examination.

RELIABILITY
When interpreting visual field data or its statistical analysis with any testing algorithm, the type and degree of any unreliable information teat may appear on the printout should be considered. FALSE -POSITIVE RESPONSES. The FP rate is the tendency to press the response button when the stimulus is not being presented.

This response is recorded as a high sensitivity value (Greater than 40 db in numeric scale) On the grey scale this results in areas that are very light or produces white scotomas representing peaks of high sensitivity. When the test show meaningfully high sensitivity values in more than 15% of the points it results in to consequences- the GHT indicating abnormally high sensitivity The pattern deviation plot showing erroneous loss expected by the virtue of the general height correction. .

Due to high sensitivity the mean deviation index may have a strikingly positive responses .The Pattern standard deviation and the short-

56

term fluctuation are usually high due to in-consistent responses. Corrected pattern standard deviation may or may not be high When a patient responds to unseen stimulus the recorded fixation loss becomes high, not because the fixation was poor but because the patient responded to the stimulus presented at the blind spot during blind spot check for fixation loss.

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FALSE NEGATIVE RESPONSES Another form of inconsistency is the failure of the patient to respond when a visible stimulus is presented. This results in abnormally low threshold values at various

locations

Negative MD index and abnormal PSD and SF

False negative errors are mainly caused due to an inattentive or fatigued patient or when the patient does not comprehend the test. The patient becomes less responsive as the examination proceeds wherein the primary points tested during the start of the examination show normal sensitivity but points tested later seem to have depressed sensitivity. In such cases, the higher sensitivity values at the primary points produce a cloverleaf pattern in the grey scale printout.

FN 46%

FIXATION LOSS:
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The third official index when the Heijl-Krakau blind spot method is used for testing fixation. When the patient is not fixating at the required target then he sees as stimulus presented at the blind spot region Pseudo-loss of fixation can occur Head tilt during the examination, which mis-located the position of blind spot and gives pseudo loss of fixation. The patient could have made false positive errors (responding when stimulus presented in the blind spot area) Nasal region of the fellow eye is not occluded properly hence patient responds to stimulus in temporal filed.

ANDERSONS THREE ABNORMALITY

CRITERIA

FOR

MINIMAL

Reliable fields can be considered to have localized defect, If the pattern deviation probability plot shows a cluster of three or more non-edge points that have sensitivities occurring in fewer than 5 % of the normal population (p< 5%) and one of the points has a sensitivity that occurs in fewer than 1 % of the populating (p<1%). The pattern standard deviation value (PSD) or the corrected pattern standard deviation (CPSD) has a value that occurs in less than 5 %of the normal reliable fields. Glaucoma hemi-field testing indicating the field to be abnormal.

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SEVERITY OF A DISEASE The number of axons damaged should relate to the average defectiveness of the field, which is best represented by the mean deviation (MD) index Classification based on MD index may be appropriate when designating pathogenic severity of the disease. A visual field abnormality is considered to be: Early defect when The MD index is better than 6 db Fewer than 25%of the fields are defective in the total deviation plot at the 5%level. Fewer than 10 points of the 76 points in 30-2 pattern (approximately 7%) are defective at the 1%level: and No point in the central 5 degrees has a sensitivity less than 15 db

EARLY DEFECT

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Moderate defect exceeds one or more of the criteria required to keep it in the early defect category but does not meet the criterion to be severe.

MODERATE DEFECT

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Severe defect has any of the following An MD index worse than 12 db More than 50% of the points depressed at the 5%level. More than 20 points depressed at the 1% level A point in the central 5 degrees with 0 db sensitivity: OR Points closer than 5 degrees under fixation 15 db sensitivity in both the upper and lower hemi-fields.

SEVERE DEFECT

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Example

Disc 0.8:1 Inferior notch IOP 13 mm of Hg (with medication). Zone 1: Check if the patients date of birth is entered correctly.(correct entry in this case) Zone 2: Look for reliability parameters- Field report shows reliable performance within the permissible limits. Zone 3 & 4: Raw data and grey scale shows areas of decreased sensitivity superiorly Zone 5: Total deviation plot shows superior and inferior defects in arcuate regions. Zone 6: Pattern deviation plot after adjustment of threshold values for general height shows superior arcuate defect (seidels scotoma) corresponding to the inferior notch in the optic disc. Zone 7: Global indices shows mean deviation of 8.61 dB and PSD of 7.62dB Zone 8: Glaucoma Hemi field Test results categorizes the field report into OUTSIDE NORMAL LIMITS. Andersons classification of field defect: Moderate classification. 63

 INTERPRETATION: Superior arcuate corresponding to an inferior notch in the optic disc.

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Progression analysis
Change in the field of vision is monitored with the help of STATPAC analyzers available with Humphrey systems. The various options available to monitor patients with glaucoma are Overview Change analysis Glaucoma change probability analysis Glaucoma probability analysis

OVERVIEW PRINTOUT
It is defined as summary printout in which a whole series of test results are shown chronologically. The overview printout presents STATPAC analyses of several 30-2 or 24-2 tests on single page. STATPAC doesnt combine 10-2 with any other test patterns. The overview presents the results of each test in four formats: gray tone, numeric, total deviation probability plot, and pattern deviation probability plot. The date of the test appears to the upper left of the gray tone, and the visual acuity and pupil size are printed to the upper right of the pattern deviation probability plot. The GHT is printed to the right of the test date. The foveal threshold, fixation losses, false negative errors, false positive errors, and global indices appear below the test results. The legend to the probability symbols appears at the bottom of the printout. One example of the overview printout is shown in figure.

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CHANGE ANALYSIS It is a printout that displays statistical summaries of a series of field tests in the form of box plots and graphs of the global indices. The change analysis printout provides a visual display of additional descriptive statistics about the visual field as a whole and includes a large number of examinations on a single page. It quantifies certain parameters and like the overview printout, it can give an overall impression of a series of visual field examinations at a glance. The change analysis display includes a box plot panel across the top and several graphs of global indices of the series of examinations below the panel along with the linear regression analysis of MD. These graphical representations can include up to 16 visual field tests. Change analysis is available for the 24-2 and 30-2, as well as combination of 24-2 and 30-2 tests, but not for the 10-2 pattern. Figure 3 shows change analysis printout. Box Plot: Box plot is nothing but a modified bar graph of the threshold values. The box plot panel itself shows the series of visual field examinations selected. Box plots are helpful in making quick determination about the nature and extent of visual field change over time.

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The amount that each value deviates above (+) or below (-) the age matched STATPAC database is ranked from the best to worst points. From this ranking, STATPAC plots the extreme values of these deviations (the 100th and zero percentile, shown at top and bottom end points of the line as shown at b in fig 2), the median value (indicated by the three dark lines inside the box shown at a in fig 2) and the 85th and 15th percentile deviations (the top and bottom of the box). Extending from the top of the box (better points) is a tail that will stop at the value of the best point. Extending from the bottom of the box (worse points) is a tail that will stop at the value of the worst point. At the left of the display is a box plot representing a normal patient for that age. By comparing the height and shape of the patients box plot to that of the normal for his age, valuable information can be quickly ascertained.

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Figure 2: Box plot

Four things that have to be noted while observing the box plot are: The overall shape of the box, how elongated or compact it is. The location of the three dark lines inside the box that indicates median (a). The top and bottom end points of the line along which the box lies (b). Where the patients box is plotted against the normal scale on the left of the printout. When a series of these boxes is plotted for a succession of fields, the change in the character of the field over time can be noted, for example: I) If the box plot looks identical to normal, yet continues to be graphed lower on follow up, it indicates progressive generalized depression without development of local defects, probably secondary to a cataract. II) If the bottom of the box plot remains at about the same level and the tail begins to extend downward, it is an indication that a scotoma may be deepening. III) If the bottom of the box plot gets lower while the median remains the same, a scotoma is enlarging. IV) If the bottom of the box elongates and the top shrinks while the median is getting worse, then a scotoma is getting larger and/or new scotomas are appearing. Note that once the tail or bottom of the box reaches 22dB, no further deepening can be represented on the graph.

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69

GLAUCOMA CHANGE PROBABILITY (GCP) It is defined as comparison of threshold data in a follow up field to baseline, in which points are highlighted if they change by amounts that are larger than that typically seen in stable glaucoma patients. Similarly, MD values changing by more than typical amounts also are flagged. The GCP analysis offers point-by-point significance limits. A point that seems to be worsened from the baseline field is indicated by a filled triangle and a point which has improved from the baseline is indicated by an empty triangle. This allows analysis of smaller areas of the visual field defect and enables early detection of change. A minimum of 3 visual fields are necessary for this analysis. The GCP will average the first two visual fields and use them as the baseline The GCP format will print a grey scale and a total deviation probability plot, similar two the overview printout. The GCP will also display the degree to which each point has changed, in decibels, as compared with the baseline.

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GLAUCOMA PROBABILITY ANALYSIS Available with : SITA strategy only. Full threshold test can be used only for baseline . Programs : 30-2 and 24-2 .does not support tests performed with 10-2 or fastpac test strategy. Number of tests : Two test for baseline and up to 14 follow up tests can be included. Contents: BASELINE PRINTOUT has the following information available. Threshold value (dB) Gray tone Total deviation probability plot Pattern deviation probability plot Includes the date and type of test above the gray tone, the GHT. Foveal threshold, reliability indices and global indices Summary of the Mean deviation value Summary of Mean Deviation plot Linear regression analysis of the mean deviation Information in the FOLLOW-UP printout includes, Gray tone Pattern deviation plot Deviation from baseline plot Progression analysis probability plot. GPA alert when applicable. Progression A single solid dot indicates a point not changing by a significant amount A small open triangle - identifies degree of deterioration that is significant at the 5%level (p<0.05) A half filled triangle indicates deterioration at that point in o 2 consecutive tests A solid triangle indicates deterioration at that point in 3 consecutive tests. An X signifies that the point is out of range for analysis. GPA alert - pertains to eye as a whole and not to specific points in the visual field. o Possible progression: 3 or more points show deterioration in at least 2 consecutive tests o Likely progression: 3 or more points show deterioration in at least 3 consecutive tests 71

MERITS: Identifying progression is relatively simple with the symbols in probability plot and the GPA alert. The GPA displays warning message for unreliable tests and excludes tests with high false positive rates from use in baseline Identifies tests with marked learning effects and displays a warning message. Once a GPA printout has been taken the subsequent single field analysis report will have the GPA summary box with the probability plot and the GPA alert for subsequent followup Demerits : Full threshold test can be used only for baseline and not for follow up tests Once a point is significantly deepened, further deepening cannot be found out.

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COMPARISON OF PROGRESSION STRATEGIES

Overview What it shows

Available with

Change analysis Summary of all The change in visual field the visual field reports plotted over time 30-2, 24-2 & 30-2, 24-2 10-2 programs programs with with all test both SITA strategies & &full threshold standard & non strategy & standard standard test parameters parameters.

Glaucoma change probability Point by point analysis of a visual field & analysis of change over time 30-2, 24-2 programs with only full threshold test strategy &standard test parameters.

Glaucoma probability analysis Point by point analysis of a visual field & analysis of change over time 30-2, 24-2 programs with only SITA test strategy & standard test parameters. Full threshold can be used only as a baseline test

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Combination with other programs & strategies.

30-2 & 24-2 can be combined. 102 cannot be combined with any other tests. Up to 16 tests can be printed. Gray tone, Raw data, total & pattern deviation plots along with the reliability & global indices.

Permissible number of tests Contents

30-2 & 24-2 test programs can be combined. Calculation based on points with 24-2 program Analysis of up to 16 tests Box plot, summary of global indices, and linear regression analysis of the MD.

30-2 & 24-2 test programs can be combined. Calculation based on points with 242 program Two baseline with follow up of upto 14 tests Baseline printout with gray tone, total deviation & summary of MD with linear regression analysis. Follow-up includes gray tone, total deviation, and deviation from baseline, change probability & MD change over time.

30-2 & 24-2 test programs can be combined. Calculation based on points with 24-2 program Two baseline tests with a follow up of upto 14 tests Baseline Printout include gray tone, raw data, total & pattern deviation plots along with the reliability , global indices & summary of MD with linear regression analysis. Follow-up includes gray tone, pattern deviation, deviation from baseline, probability plot and GPA alert

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What to look for

1) Gray scale for any deepening of defects , 2) Pattern deviation plots for development of any new defects and the probability symbols changing from 5% to 1% or 0.5 %

1) Box plot to look for a) shape , b)location of median, top and bottom end points of the line & comparison with the normal scale 2) Summary of global indices 3) Linear regression analysis of mean deviation plot to show significance of the mean deviation.

Change probability plot giving statistically significant change 1) A small open triangle denotes statistically significant improvement from baseline. 2)A solid triangle degree of deterioration that is significant at the 5%level 3) A single dot () indicates a point not changing by a significant amount 4) x signifies was unable to determine probably due to deep defect At least a cluster of 3 points in areas specific for glaucoma which is confirmed on further testing.

Probability plot shows 1)A single solid dot indicates a point not changing by a significant amount 2) A small open triangle identifies degree of deterioration that is significant at the 5%level (p<0.05) 3) A half filled triangle indicates deterioration at that point in 2 consecutive tests 3) A solid triangle indicates deterioration at that point in 3 consecutive tests. 4) An X signifies that the point is out of range for analysis

3 or more points depressed at more than 10 dB Progression

Bottom and tail of the box elongating progressively in the followup

GPA alert
Possible progression 3 or more points show deterioration in at least 2 consecutive tests

Likely progression
3 or more points show deterioration in at least 3 consecutive tests
Note GPA pertains to eye as a whole and not to specific points in the visual field.

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Compact for reviewing all visual field reports which includes all parameters.

Merits

1) A series of box reveals progression over time 2) Deepening of scotoma can be reviewed by viewing the box 3) The significance of MD change can be obtained with the regression analysis

1) Gives point by point analysis. 2) Enables early detection of progression 3) MD change over time can be obtained for determining progression

1) The GPA displays warning message for unreliable tests and excludes tests with high false positive rates from use in baseline. 2) Identifies tests with marked learning effects and displays a warning message. 3) Once a GPA printout has been taken, the subsequent single field analysis report will have the GPA summary box with the probability plot and the GPA alert for subsequent follow-up.

Demerits

1) For deepening of scotoma one needs to check several visual fields manually for all points 2) Only graphical, does not give you significant level 3) Point-bypoint analysis very difficult & tedious

1) Deepening further than 22dB can not be found out 2) Location of visual field & nature of change can not be found out

1) Available only with Full threshold reports 2) Once a point is significantly deepened, further deepening cannot be found out.

1) Full threshold test can be used only for baseline and not for follow up tests 2) Once a point is significantly deepened, further deepening cannot be found out.

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NEW TECHNIQUES IN PERIMETRY

SHORT WAVELENGHT AUTOMATED PERIMETRY (SWAP) Also called the BLUE-YELLOW PERIMETRY is a recent development for early detection of glaucoma. A carefully chosen wavelength of blue light is used as the stimulus, and a specific color and brightness of yellow light is used for the background illumination. WORKING Blue-yellow perimetry isolates and measures blue-yellow ganglion cell function. The carefully chosen bright yellow background desensitizes the green and red cones, and has little effect on blue cone function. The narrow band 440 nanometer blue stimulus falls right on the peak sensitivity of blue cones. Thus, blue-yellow perimetry tests the blue cones and their ganglion cell connections. THEORIES: There are at least two theories as to why blue-yellow testing provides earlier diagnosis. One theory suggests that the blue-yellow ganglion cells are selectively damaged in early glaucoma, and thus earlier diagnosis is simply a function of testing the part of the visual system, which is damaged first. A second theory suggests that early diagnosis is achieved simply because blue-yellow perimetry tests one of several pathways of the visual system; if only a small part of the system is tested, then there is less redundancy, and loss will be discovered earlier.
NOTE: Currently SWAP can be performed only with Full threshold strategy. SITA Version of SWAP is under formation. Comparison between white-white perimetry and blueyellow perimetry

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Candidates for SWAP

Glaucoma suspects Blue-yellow testing can be utilized on patients having one or more risk factors for glaucoma, whose white-on-white field results are normal. Glaucoma patients Blue-yellow testing has been reported to be appropriate for ocular hypertensives and glaucoma patients with mild to moderate field loss Neurological patients At least one study has demonstrated that blueyellow testing may be an appropriate and useful test in identifying neurological disease As lens density testing is not needed, patients with mild to moderate cataracts may be tested using blue-yellow perimetry.

Patients who may not be good candidates Patients having significant cataracts Advanced white-on-white field loss

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FREQUENCY DOUBLING PERIMETER Frequency Doubling Testing The Frequency Doubling Technology (FDT) Perimeter is a portable device that specifically tests for visual field loss due to non-linear M-cell neuron death, typically from glaucoma. When a low spatial-frequency sinusoidal grating undergoes high temporalfrequency counter phase flicker, the grating appears to have twice as many light\dark bars and its spatial frequency appears doubled. This phenomenon is known as Frequency doubling illusion.

The FDP device randomly presents a sinusoidal grating in 1 of the 17 test areas located within the central 20 degrees of the visual field. The sinusoidal grating has a spatial frequency of 0.25 cycles per degree and undergoes a 25-Hz counter phase flicker. Advantages Shorter time Results less affected by blur, pupil size differences and It has lower test--retest variability than white on white and SWAP.

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FDP MATRIX The FDP matrix is a modification of conventional FDP visual field testing which uses a smaller stimulus size and test a larger area. The Humphrey Matrix is similar to the FDT perimetry, in that it works on the phenomenon of frequency doubling illusion. It uses a sinusoidal spatial frequency of 0.5 cycles/degree and a counter phase flicker of 18 Hz. The Matrix uses a 100 cd/m2 background illumination and a 5 degree diameter target. It has 69 test locations, which is almost similar to the HFA 30-2 (76 points). A newer threshold procedure (ZEST) for the FDT perimetry has been developed to improve efficiency and maintain or improve accuracy

FDP MATRIX

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FEATURES
Ganglion cells targeted by test Principle Strategy

HFA (White on White Perimetry) Overall sensitivity Differential light sensitivity SITA (Swedish Interactive Thresholding Algorithm) 5-8 minutes

SHORT WAVE AUTOMATED PERIMETRY (SWAP) Konio cellular pathway: Small Bistratified cells. Blue on yellow perimetry Full threshold (Bracketing strategy) 14-18 minutes

FREQUENCY DOUDLING PERIMETRY (FDP) Magno cellular pathway (My cells) Spatial contrast sensitivity MOBS (Modified binary search: Bracketing strategy) 2-4 minutes

FDP MATRIX

Magno cellular pathway (My cells) Spatial contrast sensitivity ZEST (Zippy estimate of sequential testing) 3-5 minutes

Time taken (in secs) Target characteristic: Target Type:

White light

Blue Target

Low spatial frequency (0.25 cycles/degree) and a counterphase flickers (25 Hz) 50 cd/m2 10 by 10 Square target

Low spatial frequency (0.50cycles/degree) and counterphase flickers (18 Hz) 100 cd/m2 5 by 5 Square target

Back ground: Size:

31.5 apostilb Goldmann Size III (16 mm2): Commonly used HFA (30-2): 76 points Present

Yellow light: 100 cd/m2 Goldmann Size V (64 mm2)

Number of test points in a 30 field Glaucoma Hemifield test (GHT) Refractive correction Advantages

19 test locations Present Absent

69 test location Present

Calculated correction: to be placed in the trial frame Gold standard

Calculated correction: to be placed in the trial frame Early glaucomatous loss detection - Long - Sensitive to blur and media opacities

Not required to correct till ( 7 D Spherical equivalent) - Screening and fast - Very reproducible - May miss focal defects

Disadvantages

Defect appears: after 30 40% nerve fiber loss

Not required to correct till ( 4 D Spherical equivalent) - Screening and fast - Pattern of loss is more comparable to SITA reports - Lack of longitudinal studies 81

HIGH PASS RESOLUTION PERIMETRY The perimetry is designed to measure the response of parvo cellular mechanism. The P cells handle acuity and resolution tasks and prefer stimuli with low temporal frequencies and high spatial frequencies, along with color. The test presents spatially filtered rings across 50 test locations in a 30-degree visual field. Fourteen different ring step sizes are used, with threshold designated as the smallest ring size that can be resolved by the patient.

A normal field report with different ring sizes.

An inferior arcuate defect where even the largest stimulus size was not perceived

TENDENCY ORIENTED PERIMETRY The tendency-oriented perimetry (TOP) is an accelerated thresholding algorithm incorporated in the octopus perimeter. The TOP algorithm uses a subjects response at a given point, not only to estimate the sensitivity at that point, but also to modify the sensitivity estimate of surrounding points within the visual field. Stimuli are presented only once at each test location, resulting in a marked reduction in test times compared with conventional staircase strategies and allowing the sensitivity of the visual field to be estimated in approximately 2.5 minutes.

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PRACTICAL TIPS BASIC Selection of test strategy and program to be done based on the clinical finding A threshold strategy should be used when the estimation of defect depth is required. It is advisable to follow up patients with the same instrument and test strategy. Switching between strategies might lead to difficulty in analyzing the defect, more particularly in cases where progression is suspected. DURING EXAMINATION The patient should be explained about the importance of the test to obtain good reliability. Make sure that the patient is seated comfortably as discomfort can affect reliability. While entering patient data, take care to enter patients age correctly as this can lead to misinterpretation of visual field result when wrongly entered. Watch out for droopy lids, deep-set eyes and perform necessary work such as taping eyelids before starting the test as these can induce artefactual report. Trial lens correction should be placed as close as possible to the patients eyes. Contact lens correction should be used for refractive errors greater than +/- 6 DS Try using the diamond fixation targets for patients with suspected central scotomas to aid patient fixate better at the target. The fovea threshold value needs to be correlated with the visual acuity and the clinical picture and the test has to be repeated if the value does not correlate. When the patients are performing the test, the threshold points needs to be correlated with the clinical fundus feature Adequate breaks should be given in-between visual field testing to improve patient performance and avoid fatigue effects. Periodic monitoring of the patients chin and head position is necessary to avoid artifacts. Test speed (time interval between stimulus presentation and response) can be decreased for slow responders.
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 Fixation losses are not only because of eye deviations. Look for other possible causes ( causes explained in text) Additional programs/ strategy should be used whenever required Dilated fields need to be done for patients with the presence of media opacity and miotic pupils AFTER EXAMINATION Interpretation of a field report should not be done without the knowledge of clinical findings / fundus picture Before interpreting a visual field report check o If the report belongs to the patient being examined o If the age of the patient is correct o If proper refractive correction has been used. o If the pupil diameter was adequate for providing accurate results. o If the correct test strategy has been employed. o If the test results are reliable o Whether the report belongs to the tested eye, to rule out chances of the selecting one eye and occluding the same eye. o Possible artifacts like clover leaf, white scotoma, lid artifact, edge and refractive artifacts should be kept in mind while interpreting a field report Progression of visual field should be confirmed only after repeated testing

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QUIZ 1. A superior retinal pathology will result in a superior visual field defect true/false 2. Nasal field is the largest among all quadrants true/false 3. is an example of physiological absolute scotoma 4. CPSD is not available with SITA because 5. The field of vision increases towards periphery true/false 6. Foveal threshold depends on 7. Brightest stimulus in Goldmann Perimeter is 10,000 asb. True/false 8. Heijl Krakau method is used to estimate fixation losses. True/false 9. SITA strategy is available for stimulus size V in HFA True/false 10. Expand (a). SWAP (b). SITA 11. Apostilb and decibel units are inversely related to each other. True/false 12. Fixation monitor is efficiently done with gaze tracking. True/false 13. TOP strategy is available in HFA True/false 14. Confrontation cannot be used to estimate visual field. True/false 15. Stimulus intensity between HFA & Octopus perimetry cannot be compared. True/false 16. SWAP is based on differential light sensitivity True/false 17. Supra threshold detects subtle abnormalities. True/false 18. Number of points tested in 30-2 program is 19. In Full threshold strategy the values obtained within brackets are called and are used to calculate 20. Interval between two points in 10-2 strategy is 21. Preferred testing program for patients with retinitis pigmentosa 22. Size of Goldman III target 23. Progression analysis can be done in Goldmann perimeter true/false 24. The higher the apostilbs the better the visual field true/false 25. Typical pattern in the gray scale in a report with high false positive errors 26. Permissible Limits For False Positives , false negative and fixation losses. 27. Pupil size does not influence the visual field True/false 30 Interpret this visual field report

a) Fundus : 0.6 : 1 CDR with normal neural rim and otherwise normal posterior pole.

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