PRACTICAL AUTOMATED

VISUAL FIELD
INTERPRETATION

CYNTHIA V. VERZOSA, MD, DPBO, MSC

ON BEHALF OF THE
DR. GERTRUDE GWENDALE BARON-REINOSO

No financial disclosures

Philippine Glaucoma Society Roadshow 2019-2020

VISUAL FIELD
INTERNATIONAL PERIMETRIC SOCIETY 1978

• THE PORTION OF THE EXTERNAL

ENVIRONMENT OF THE OBSERVER WHEREIN
THE STEADILY FIXATING EYE CAN DETECT
VISUAL STIMULI

• EXTENDS 60 DEGREES SUPERIORLY, 75 DEGREES

INFERIORLY, 60 DEGREES NASALLY, 100
DEGREES TEMPORALLY

Philippine Glaucoma Society Roadshow 2019-2020

PERIMETRY
• MEASUREMENT OF DIFFERENTIAL LIGHT SENSITIVITY
OR THE ABILITY OF A SUBJECT TO DISTINGUISH A LIGHT
STIMULUS FROM BACKGROUND ILLUMINATION AT
TOPOGRAPHICALLY DEFINED LOCI IN THE VISUAL FIELD

• STANDARD AUTOMATED PERIMETRY (SAP) IS A FORM OF

STATIC PERIMETRY WHERE STIMULI ARE PRESENTED IN
RANDOM ORDER AT PREDETERMINED LOCATIONS IN THE
VISUAL FIELD

AMERICAN ACADEMY
OF OPHTHALMOLOGY

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TRAQUAIR’S ISLAND OF VISION

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STANDARD AUTOMATED PERIMETRY
(WHITE ON WHITE PERIMETRY)

• STIMULUS SIZE GOLDMANNN SIZE III (USUAL)

GOLDMANN SIZE V (LOW
VISION)

• BACKGROUND ILLUMINATION 31.5 APOSTILBS

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STIMULUS SIZE

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LIGHT INTENSITY VS LIGHT SENSITIVITY

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THRESHOLD STRATEGY: BRACKETING 4-2

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NORMAL HILL VS ABNORMAL HILL

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EXTENT OF FIELD TESTED

• CENTRAL 30 DEGREES : MOST EARLY DEFECTS ARE

DETECTED HERE, MORE EFFICIENT, MORE ACCURATE
NOT COMMON TO FIND A PERIPHERAL DEFECT WITH
CENTRAL EXTENSION IN GLAUCOMA

• CENTRAL 24 DEGREES : GOOD SCREENING TEST WITH THE

PERIPHERAL RING OF THE 30 DEGREE TEST OMITTED

• CENTRAL 10 DEGREES: FOR SEVERELY CONSTRICTED

FIELDS

Philippine Glaucoma Society Roadshow 2019-2020

COMMONLY USED STATIC PERIMETERS
Specifications Humphrey VFA Octopus Perimeter
Background 31.5 Asb 31.4 Asb
Luminance (0 dB) 10,000 Asb 4000 Asb
Stimulus time 200 ms 100 ms
dB range 0 to 51 0 to 47
Program 30-2/ 24-2 G2/ 32/ 30-2
Number of test points 76/ 54 59/ 2 phases
Spacing Equal at 6 degrees Unequal at 2.8 degrees,
greater spacing
peripherally
Strategy Full Threhhold Full Threshhold
SITA standard 4-2 G-Dynamic
SITA fast 3-1 G-TOP

Philippine Glaucoma Society Roadshow 2019-2020

WHAT TEST TO ORDER?
Strategy Humphrey Octopus Pros Comments
Full Full Full Sensitive Tedious
threshhold threshhold Artifacts
Fatigue
12-15 min
Balanced SITA Dynamic Short Preferred
Modified Standard Sensitive 7-9 min
threshhold Reliable
SITA Fast TOP Very fast for For children,
low attention very elderly.
Fast spans 3-5 min

SITA (Swedish Interactive Threshhold Algorithm)

TOP (Tendency Oriented Program)

Philippine Glaucoma Society Roadshow 2019-2020

WHAT TEST TO ORDER?

Program Humphrey Octopus Pros Comments

Low Vision Goldmann V LVC For VA <20/200
stimulus monitoring
advanced
glaucoma
Central 10 10-2 M2 More For severely
degrees sensitive constricted
centrally fields
Split fixation
Central island

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THE
HUMPHREY
PRINTOUT

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THE
OCTOPUS
PRINTOUT

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SYSTEMATIC EVALUATION OF THE VISUAL
FIELD PRINTOUT

• 1) GENERAL DATA & PARAMETERS

• 2) RELIABILITY INDICES
• 3) ACTUAL VALUES & GRAYSCALE
• 4) PATTERN DEVIATION PLOT/ CORRECTED PROBABILITY PLOT
• 5) GLOBAL INDICES
• 6) SPECIAL TESTS : GLAUCOMA HEMIFIELD TEST (HUMPHREY)
CUMULATIVE DEFECT
CURVE/BEBIE CURVE (OCTOPUS)

Philippine Glaucoma Society Roadshow 2019-2020

GENERAL DATA & PARAMETERS: PEARLS

• 1. PATIENT NAME SHOULD BE EXACTLY THE SAME FOR ALL TESTS (SPELLING)

• 2. BIRTHDATE AND AGE SHOULD BE ACCURATE – AGE MATCHED NORMATIVE

DATABASE

• 3. DATE OF TEST – FOR MONITORING PROGRESSION

• 4. PUPIL SIZE - NO EXTREMES (NOT <3, NOT >6 MM)

• 5. REFRACTION – CORRECT THE HYPEROPIA, ASTIGMATISM, MYOPIA

PREVENT LENS RIM ARTIFACTS, READING ADDS AS NEEDED

• 6. VISUAL ACUITY – IF <20/200 USE LOW VISION OR STIMULUS SIZE V PROGRAM

• 7. TYPE OF PROGRAM/STRATEGY USED - SHOULD BE APPROPRIATE & CONSISTENT

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IS THE TEST RELIABLE?
1. TEST DURATION –PROLONGED TEST TIME MAY INDICATE
UNRELIABILITY
2. FALSE POSITIVE ERROR / POSITIVE CATCH TRIALS – PATIENT
RESPONDED EVEN IF NO LIGHT WAS PRESENTED
- TRIGGER HAPPY PATIENT
- LESS THAN 20% TO BE RELIABLE
3. FALSE NEGATIVE ERROR / NEGATIVE CATCH TRIALS – NO RESPONSE
TO A BRIGHT STIMULUS AT THE AREA WHERE A DIMMER STIMULUS
WAS PREVIOUSLY SEEN
- INATTENTIVE PATIENT, EDGE OF SCOTOMAS, ADVANCED
GLAUCOMA
- LESS THAN 20% TO BE RELIABLE
4. FIXATION LOSSES (H) – THE PATIENT RESPONDS TO A STIMULUS AT THE
BLIND SPOT
- CHECK GAZE TRACKER
5. RELIABILITY FACTOR (O) – <15
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HIGH FALSE POSITIVE HIGH FALSE NEGATIVE

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GENERAL DATA
RELIABILITY INDICES

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GRAYSCALE
ACTUAL VALUES

• MAY BE USEFUL IN
EXPLAINING THE
RESULTS TO THE
PATIENT
• NOT USED FOR
INTERPRETATION
• QUICK SCAN FOR
EXTREMES IN THE
ACTUAL VALUES

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PROBABILITY PLOTS: THE MOST IMPORTANT PART

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PATTERN DEVIATION AND CORRECTED
PROBABILITY PLOTS
• MOST IMPORTANT PARAMETER IN EVALUATING THE VISUAL
FIELD FOR GLAUCOMATOUS DEFECTS
• AGE CORRECTED, COMPARED STATISTICALLY TO THE
NORMATIVE DATABASE
• TOTAL DEVIATION PLOT & PROBABILITY PLOT: TOTAL
DEFECTS
HEIGHT OF THE HILL
• PATTERN DEVIATION PLOT & CORRECTED PROBABILITY
PLOTS :
TAKES AWAY THE GENERALIZED DEPRESSION COMPONENT
TO ACCENTUATE THE SHAPE OR SMOOTHNESS OF THE HILL
(FOCAL DEFECTS)

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COMPARING TOTAL DEVIATION AND
PATTERN DEVIATION PLOTS

• 1. GENERALIZED DEPRESSION ONLY

• 2. FOCAL DEFECT ONLY
• 3. COMBINED GENERALIZED AND FOCAL DEFECT

• 4. IDENTIFY STATISTICALLY SIGNIFICANT POINTS

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EXAMPLES:
TD VS. PD PLOTS

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FEATURES OF SIGNIFICANT GLAUCOMATOUS
FIELD DEFECTS
ANDERSON & HODAPP, AUTOMATED PERIMETRY 1999

1. A CLUSTER OF 3 OR MORE DEPRESSED NON-EDGE POINTS WITH

P < 5 %,
AND AT LEAST 1 POINT WITH P < 1 %
2. DEEP FOCAL DEFECT < 3 IN NUMBER MAY BE CONSIDERED, IF
FOUND IN CERTAIN AREAS: NASAL STEP, TEMPORAL WEDGE,
PARACENTRAL AREA

3. FOLLOWS THE RNFL PATTERN

4. RESPECTS THE HORIZONTAL MERIDIAN
5. REPRODUCIBLE IN SUBSEQUENT TESTS

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GLAUCOMA
PATTERNS

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GLOBAL INDICES

HUMPHREY OCTOPUS

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GLOBAL INDICES MADE EASY

Indices/Meanings Humphrey Octopus

Average Sensitivity MS (Mean Sensitivity)
Average deviation from MD (Mean Deviation) MD +/-2
age corrected normals +/- 2
Shape/Focal defects PSD (Pattern Standard LV (Loss Variance)
Deviation)
Equal or < 6 Equal or < 6

Intratest Variability SF (Short term SF 2

when retesting points fluctuation)
2
Focal Defects corrected Corrected PSD Corrected LV
for SF (CPSD) 4 (CLV) 4

Philippine Glaucoma Society Roadshow 2019-2020

HUMPHREY GHT (GLAUCOMA HEMIFIELD
TEST)
VFI (VISUAL FIELD INDEX)

GHT
1. Abnormally High Sensitivity
2. Within Normal Limits
3. Borderline
4. Generalized Reduction of
Sensitivity
5. Outside Normal Limits

VFI expressed as a percentage of

normal function and is not influenced
by diffuse field loss

Philippine Glaucoma Society Roadshow 2019-2020

OCTOPUS CUMULATIVE DEFECT CURVE
(BEBIE CURVE)

OCTOPUS TRAINING MODULE (HAAG-STREIT) *points ranked from most to least sensitive

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IS THIS A GLAUCOMATOUS DEFECT?

3 MINIMUM CRITERIA FOR GLAUCOMA DEFECTS

1. PD PLOT – THREE OR MORE NON-EDGE POINTS P<5%,
WITH ONE POINT P<1%
CLUSTERED IN AN ARCUATE AREA
2. CPSD OR PSD – ABNORMAL P<5%
3. ABNORMAL GHT
ANDERSON DR, PATELLA VM. AUTOMATED
STATIC PERIMETRY 1999

Philippine Glaucoma Society Roadshow 2019-2020

IS THIS A GLAUCOMATOUS DEFECT?
BEWARE OF ARTIFACTS
ESTABLISH A BASELINE (AT LEAST 2 FIELDS)

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CORRELATE THE VISUAL FIELD DEFECT WITH A
STRUCTURAL DEFECT (OPTIC DISC & RNFL)

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EVALUATE THE SEVERITY OF THE DEFECT

DEFECT MD NO. OF POINTS CENTRAL 5

IN THE PD DEGREES
PLOT
EARLY < -6 dB <18 p < 5% No point <15dB
<10 p < 1%
MODERATE < -12 dB <37 p <5% No point 0 dB
<20 p <1% Only one
hemifield with
<15 dB
ADVANCED > -12 dB >37 p <5% With 0 dB point
>20 p <1% Both hemifields
with <15dB

Hodapp – Parrish – Anderson Classification (HFA Full Threshhold)

Philippine Glaucoma Society Roadshow 2019-2020

MONITOR GLAUCOMA PROGRESSION
• 1. GET AS MANY BASELINE FIELDS AS NECESSARY – RESULT
SHOULD BE RELIABLE AND REPRODUCIBLE
(TWO OR MORE)
• 2. CONFIRM PROGRESSION IN AT LEAST THREE TESTS -
REPRODUCIBILITY
• 3. COMPARE TESTS ONLY IF THEY USE THE SAME
STRATEGY/PROGRAM
• 4. SIGNS OF GLAUCOMA PROGRESSION
A. WIDENING OF AN EXISTING DEFECT
B. DEEPENING OF AN EXISTING DEFECT
C. DEVELOPMENT OF A NEW DEFECT

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GLAUCOMA PROGRESSION ANALYSIS (HFA)

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OCTOPUS PROGRESSION ANALYSIS

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CORRELATE AVF RESULTS WITH CLINICAL OPTIC
NERVE AND RNFL FINDINGS PLUS STRUCTURAL
TESTS

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PRACTICE MAKES PERFECT

THANK YOU!

Philippine Glaucoma Society Roadshow 2019-2020