8th edition

VISUAL FIELD DIGEST

A guide to perimetry and the Octopus perimeter

4.1
2.1

-0.8 6.7
2.6
0.4
1.0 0.4

0.7
0.6

Lyne Racette, Monika Fischer, Hans Bebie,

Gábor Holló, Chris A. Johnson, Chota Matsumoto

Illustrated by Philip Earnhart

8th edition

VISUAL FIELD DIGEST

A guide to perimetry and the Octopus perimeter

Lyne Racette, Monika Fischer, Hans Bebie,

Gábor Holló, Chris A. Johnson, Chota Matsumoto

Illustrated by Philip Earnhart

Editor:
Haag-Streit AG, Köniz, Switzerland

8 Edition, published 2019

Layout, cover design & illustrations by Philip Earnhart

ISBN 978-3-033-07419-4
HS Art. No. 1519.7020038.02080

Copyright © 2019 HAAG-STREIT AG

Haag-Streit AG allows the use of this publication for personal or academic use under the conditions that (i) it is used without commercial
purpose and (ii) the content is reproduced exactly as the original by mentioning Haag-Streit AG, Switzerland as the owner of the copyright.

Non-academic, non-personal or commercial users might only use this publication in whole or in part after a written authorization by the
copyright holder.

Trademark statement
“Haag-Streit”, “900” and “Octopus” are either registered trademarks or trademarks of Haag-Streit Holding AG.

The following are either registered trademarks or trademarks of Carl Zeiss Meditec: “Guided Progression Analysis”, “GPA”, “Humphrey”, “HFA”,
“SITA”, “SITA Fast”, “SITA Standard”, “Visual Field Index”, and “VFI”.
 III

AUTHORS & CONTRIBUTORS

AUTHORS CONTRIBUTORS
LYNE RACETTE, PhD JONATHAN MYERS, MD
Associate Professor Chief of Glaucoma Service
Callahan Eye Hospital & Clinics Wills Eye Hospital
Department of Ophthalmology Philadelphia, USA
University of Alabama at Birmingham
Birmingham, USA RAMANARASIAH RANGARAJ, MD
Consultant Surgeon & Head of
MONIKA FISCHER, MSc the Department of Ophthalmology
Senior Market Manager Perimetry Premier Eye Care And Surgical Center
Haag-Streit AG Chennai, INDIA
Köniz, SWITZERLAND
FIONA ROWE, PhD
HANS BEBIE, PhD Professor of Orthoptics
Professor Emeritus Orthoptics and Health Services Research
Institute for Theoretical Physics Institute of Psychology, Health and Society
University of Bern University of Liverpool
Bern, SWITZERLAND Liverpool, UNITED KINGDOM

GÁBOR HOLLÓ, MD, PhD, DSc SONOKO TAKADA MD, PhD

Professor of Ophthalmology Adjunct Assistant Professor
Director of Glaucoma and Perimetry Unit Department of Ophthalmology
Department of Ophthalmology Kindai University Faculty of Medicine
Semmelweis University Osaka-Sayama, JAPAN
Budapest, HUNGARY

CHRIS A. JOHNSON, PhD, DSc ILLUSTRATOR

Professor Emeritus
Department of Ophthalmology & Visual Sciences PHILIP EARNHART
University of Iowa Art, Communication & Design
Iowa City, USA earnhart.ch
Biel, SWITZERLAND
CHOTA MATSUMOTO, MD, PhD
Professor of Ophthalmology
Department of Ophthalmology,
Kindai University Faculty of Medicine
Osaka-Sayama, JAPAN
Preface V

PREFACE
Since the introduction of the manual Goldmann perime- This book was written with the intention of making vi-
ter in 1946, perimetry has become an indispensable tool sual ield testing accessible to everyone, including clini-
in any eye care practice. In the last ten years, clinicians’ cians, residents, researchers, examiners, students and
expectations regarding visual ield testing and analysis those without previous knowledge of perimetry. Much
have signiicantly increased. In today’s busy and fast- effort has been invested in creating instructive illustra-
paced clinics, maximizing the trade-off between result tions to support the text’s key points. At the same time,
accuracy, test duration and the effort required from both it provides in-depth information for anyone wanting to
the patient and the examiner is more important than know more about visual ield testing theory.
ever before.
The 6th and the subsequent 7th edition – containing minor
While the basic testing principles used in perimetry to- corrections and updates – have been highly appreciated
day have remained largely unchanged since the introduc- by visual ield testing students, technicians, clinicians
tion of the manual Goldmann perimeter in 1946, Octopus and experts. Since 2016, all ten thousand hardcopies of
perimeters have pioneered numerous important changes this book have been distributed, which calls for a slightly
in perimetry. The development of the irst automated pe- amended 8th edition with updated references and minor
rimeter in 1974, the Octopus 201, by Fankhauser, Spahr corrections.
und Jenni, opened the door for automated perimetric
We wish to thank our readers for all the positive feedback
testing as we know it today. In addition, the Octopus pe-
we have received in the last three years with regards to
rimeter’s introduction of semi-automation in kinetic pe-
both the content and Philip Earnhart’s easy-to-under-
rimetry over 20 years ago has facilitated kinetic testing.
stand graphics. Furthermore, this book would not have
Since then, knowledge on how to best select, perform been possible without the unfailing support of Haag-St-
and interpret perimetric tests in clinical practice has reit AG, for which we are grateful. Finally, we should like
increased considerably. Normative databases, global in- to thank our contributors for providing us with the clin-
dices such as Mean Defect, the Defect Curve and many ical cases used throughout the book to illustrate various
other useful tools for analyzing the measured sensitivity aspects of perimetry and for sharing their knowledge
thresholds were irst introduced on Octopus perimeters with us.
before becoming worldwide standards for visual ield in-
We hope that this book on perimetry in general, and on
terpretation.
the Octopus perimeter in particular, is not only compre-
In the last decade, several advances in testing with Oc- hensive but also enjoyable to read for anyone interested
topus perimeters have been achieved. EyeSuite Progres- in visual ield testing. We are convinced that the informa-
sion Analysis has been developed into a powerful tool for tion shared in the pages ahead will be useful to clinicians
assessing progression. In addition, both Cluster Analysis and ultimately to their patients, whose sight we deeply
and Polar Analysis are helpful features for establishing care about. We wish you an enriching and pleasant read-
a relationship between functional and structural results. ing experience.

In 2016, Haag-Streit published the completely reviewed

6th edition of the Visual Field Digest, with greater empha-
Lyne Racette, Monika Fischer, Hans Bebie, Gábor Holló,
sis on the challenges and possible pitfalls associated with
Chris A. Johnson, Chota Matsumoto.
visual ield testing in clinical practice and guidance on
how to avoid and overcome them. September 2019
VI Table of contents

TABLE OF CONTENTS
1. INTRODUCTION 1
WHY READ THIS BOOK 1
WHO SHOULD READ THIS BOOK 1
HOW TO READ THIS BOOK 2
CONTENT AT A GLANCE 3

2. WHAT IS PERIMETRY 7
INTRODUCTION 7
Perimetry – A standard test in ophthalmology 7
THE NORMAL VISUAL FIELD 8
Spatial extent of the visual ield 8
Sensitivity to light in the visual ield 9
The hill of vision – A visualization of visual function 10
MEASURING SENSITIVITY TO LIGHT ACROSS THE VISUAL FIELD 11
Perimetry allows quantiication of abnormal sensitivity to light 11
The perimetric test 12
DISPLAY OF SENSITIVITY THRESHOLDS 14
The decibel scale used in Perimetry 14
Graphic display of sensitivity thresholds 16
CHALLENGES IN VISUAL FIELD TESTING AND INTERPRETATION 17
Perimetric testing has low resolution 17
Normal sensitivities depend on age and test location 18
Perimetry has objective and subjective components 20
Normal luctuation depends on test locations and disease severity 20
Clinical standard for visual function testing 22

3. HOW TO PERFORM PERIMETRY YOU CAN TRUST 25

INTRODUCTION 25
Perimetry – A subjective test 25
Perimetry – Need for a team approach 26
The important role of the doctor 26
The important role of the visual ield examiner 27
HOW TO PERFORM VISUAL FIELD TESTING 28
Setting up the perimeter 28
Placing an adequate trial lens 29
Instructing the patient 29
Setting up and positioning the patient 31
Monitoring the patient during the examination 35
Table of contents VII

COMMON PITFALLS TO AVOID 37

Inconsistent patient behavior 37
Mistakes in the set-up procedure 40
External obstructions blocking stimuli from reaching the retina 43
Clinical relevance of untrustworthy visual ields 45

4. KEY EXAMINATION PARAMETERS 47

FIXED EXAMINATION PARAMETERS 47
PATIENT-SPECIFIC EXAMINATION PARAMETERS 48
Type of perimetry: Static or kinetic perimetry 48
Stimulus type: Standard or non-conventional 51
Test pattern 54
Test strategy 56

5. SELECTING A TEST PATTERN 59

INTRODUCTION 59
TEST PATTERNS FOR GLAUCOMA 60
Typical visual ield defects in glaucoma 60
Standard test pattern in glaucoma care 62
Alternative test patterns for the central 30° 64
Further test patterns for glaucoma 65
TEST PATTERNS FOR NEUROLOGICAL VISUAL FIELD LOSS 67
Typical visual ield defects in neuro-ophthalmic conditions 67
Thorough assessment of neurological visual ield defects 69
TEST PATTERNS FOR RETINOPATHIES 70
Typical visual ield defects in retinopathies 70
Test patterns for the macula 71
Test patterns for the full ield 72
TEST PATTERNS FOR VISUAL ABILITY TESTING 74
Test patterns for visual ability to drive 74
Test patterns for blepharoptosis 76
Test patterns for visual impairment 78

6. SELECTING A TEST STRATEGY 81

INTRODUCTION 81
QUANTITATIVE STRATEGIES 82
Normal strategy 83
Dynamic strategy 85
Low-vision strategy 86
Tendency-Oriented-Perimetry (TOP) strategy 87
QUALITATIVE STRATEGIES 90
1-Level Test strategy (two-zone strategy) 91
Screening-P95 strategy 92
2-Level Test strategy (three-zone strategy) 94
RECOMMENDATIONS ON KEY EXAMINATION PARAMETERS 96
VIII Table of contents

7. OVERVIEW OF VISUAL FIELD REPRESENTATIONS 99

INTRODUCTION 99
RELATIONSHIP AMONG OCTOPUS VISUAL FIELD REPRESENTATIONS 99
REPRESENTATIONS DISPLAYING SENSITIVITY THRESHOLDS 101
Values 101
Grayscale of Values 102
REPRESENTATIONS BASED ON COMPARISONS WITH NORMAL 103
Comparisons 103
Grayscale of Comparisons 105
Probabilities 107
Defect Curve 109
Cluster Analysis 110
Polar Analysis 113
REPRESENTATIONS BASED ON COMPARISONS WITH NORMAL,
CORRECTED FOR DIFFUSE DEFECT 115
Corrected Comparisons 115
Grayscale of Corrected Comparisons 117
Corrected Probabilities 118
Corrected Cluster Analysis 118
GLOBAL INDICES 118
Mean Sensitivity (MS) 119
Mean Defect (MD) 119
Square root of Loss Variance (sLV) 120
Corrected square root of Loss Variance (CsLV) 121
Diffuse Defect (DD) 121
Local Defect (LD) 122
RELIABILITY INDICES 123
False Positive (FP) answers 123
False Negative (FN) answers 124
Reliability Factor (RF) 124
Short-term Fluctuation (SF) 124

8. CLINICAL INTERPRETATION OF A VISUAL FIELD 127

INTRODUCTION 127
STEP-BY-STEP INTERPRETATION OF A VISUAL FIELD 134
Overview of step-by-step worklow 134
Step 1 – Conirm patient and examination parameters 135
Step 2 – Determine whether the visual ield can be trusted 136
Step 3 – Identify diffuse visual ield defects 140
Step 4 – Distinguish between normal and abnormal visual ields 145
Step 5 – Assess shape and depth of defect 149
Step 6 – Assess cluster defects in glaucoma 152
Step 7 – Where to look for a structural defects 155
Step 8 – Assess severity 159
Table of contents IX

9. INTERPRETATION OF VISUAL FIELD PROGRESSION 165

INTRODUCTION 165
ASSESSMENT OF GLOBAL VISUAL FIELD CHANGE 168
Change of Mean Defect (MD) as a measure of global change 168
Trend analysis for the visualization of change 168
Using probabilities to distinguish between stable and changing visual ield series 171
MD Trend Analysis 174
Interpretation of MD Trend Analysis 176
Selection of adequate visual ields for analysis 176
DISTINCTION BETWEEN LOCAL AND DIFFUSE CHANGE 178
Importance of distinction between local and diffuse change 178
Use of Diffuse Defect index (DD) to identify diffuse change 179
Use of Local Defect index (LD) to identify local change 180
Use of square root of Loss Variance (sLV) to identify local change 180
Clinical interpretation of 4 Global Trend Analyses 181
CLUSTER TREND AND CORRECTED CLUSTER TREND ANALYSIS 183
Importance of assessing cluster progression in glaucoma 183
Cluster Trend and Corrected Cluster Trend Analysis 183
POLAR TREND ANALYSIS 187
Importance of establishing a relationship between structural and functional progression 187
Use of polar trend analysis to assist in the detection of glaucomatous structural progression 187

10. NON-CONVENTIONAL PERIMETRY 193

INTRODUCTION 193
FUNCTION-SPECIFIC PERIMETRY 194
Rational for using function-speciic perimetry 194
Use of function-speciic perimetry in clinical practice 195
Pulsar Perimetry 196
Flicker Perimetry 198
Short Wavelength Automated Perimetry (SWAP) 200
STIMULUS V FOR PATIENTS WITH LOW VISION 201

11. KINETIC PERIMETRY 205

WHAT IS KINETIC PERIMETRY 205
Limitations of static perimetry 205
Description of kinetic perimetry 207
WHY PERFORM KINETIC PERIMETRY 210
Beneits of kinetic perimetry 210
Limitations of kinetic perimetry 212
HOW TO PERFORM KINETIC PERIMETRY 214
The Goldmann perimeter: Kinetic visual ield testing 214
Key decisions in kinetic perimetry 215
Stimulus types 216
General testing methodologies 218
Step-by-Step example of kinetic perimetry 227
Automation of kinetic perimetry 230
X Table of contents

12. TRANSITIONING TO A DIFFERENT PERIMETER MODEL 235

INTRODUCTION 235
GENERAL ASPECTS OF TRANSITIONING 236
Measured sensitivity thresholds cannot be compared across different perimeter models 236
Device-speciic normative databases allow comparison of sensitivity losses between devices 237
Import of existing data to ensure continuity 239
Managing patient-related luctuation 243
SPECIFIC ASPECTS RELATED TO TRANSITIONING FROM THE HUMPHREY FIELD ANALYZER 243
Selection of test parameters 243
Interpretation of a single visual ield 244
Interpretation of visual ield progression 250

13. CLINICAL CASES 255

INTRODUCTION 255
GLAUCOMA – SINGLE FIELD 257
GLAUCOMA – TREND 266
NEUROLOGICAL DISEASES 272
RETINAL DISEASES 280

INDEX 285
 1

CHAPTER 1
INTRODUCTION

WHY READ THIS BOOK

The Visual Field Digest is a comprehensive guide to Thanks to its many instructive illustrations to explain
perimetry and the Octopus perimeter. It explains core key points, this book will make visual field testing
concepts and provides details about the Octopus vi- accessible to anyone and has been enjoyed by tens
sual field machine. It also places great emphasis on of thousands of eye care professionals since its first
the clinical challenges and pitfalls of visual field test- publication in 1983.
ing and gives guidance on how to avoid and overcome
them.

WHO SHOULD READ THIS BOOK

This book has been written for any current or future care professionals and provides many practical tips and
eye care professional who perform or interpret visual tricks to get even more out of their perimetric testing.
ield examinations as part of their diagnostic routine. And last, it has been written for researchers and expert
This group not only includes clinicians in optometry users of perimetry who are interested in the scientiic
and ophthalmology, but also visual ield examiners who background of perimetry and the Octopus perimeter.
administer perimetric tests to patients.
While this book provides in-depth information about
A wide range of users will ind useful information in the design and use of the Octopus perimeters, it is also
this book. It has been created for students with limited very useful reading for users of other perimeter brands,
knowledge in perimetry and therefore explains funda- as the fundamental concepts of perimetry are compara-
mentals in perimetry in an easy to understand manner. ble among perimeter brands and are illustrated in this
In addition, it has been composed for experienced eye book in an easy to understand way.
2 Chapter 1 | I ntroduc tion

HOW TO READ THIS BOOK

To cater to the needs of readers with different experi- For more experienced users, individual chapters or sec-
ence levels as well as different learning styles, this book tions in this book can also be read individually, as each
can be read in several ways. chapter is structured in a way that it is self-explanatory,
or if not, a clear reference to another chapter is given.
For students and inexperienced users in perimetry, this
book is structured in a way that, when read from begin- To find and understand key information quickly, all
ning to end, it allows the content to be followed with essential concepts are graphically illustrated to support
minimal prior knowledge. For this reason, the book a quick understanding of the concept. With more than
starts with fundamentals of perimetry such as, what the 200 graphics available in this book, it is thus possible
test does, how to administer the test and how to choose to grasp key information just by looking at the graphics
test parameters, before moving on to visual ield inter- and reading the captions.
pretation and special topics like kinetic perimetry or
function-speciic perimetry. To tie the learning to real If several choices or methods are compared, overview
clinical situations, this book concludes with a case pre- tables are provided for quick comparison between
sentation section. them. Sometimes, in-depth background information

KEY ELEMENTS USED IN THIS BOOK

P atient- spec ific ex am ination param eters 5 1 5 2 Chapter 4 | K ey ex am ination param eters
TABLE
Provides a quick
overview and
contrasts different
concepts/methods
COMPARISON BETWEEN STATIC AND KINETIC PERIMETRY TABLE 4-1
BOX 4B GOLDMANN SIZES I TO V

STATIC KINETIC Š‡•‹œ‡…‘˜‡–‹‘•—•‡†–‘†ƒ›–‘†‡•…”‹„‡ƒ

’‡”‹‡–”‹…•–‹—Ž—•ƒ”‡†‡”‹˜‡†ˆ”‘–Š‡™‘” BLIND SPOT V 1.7°
‘ˆ”‘ˆ‡••‘”ƒ•
‘Ž†ƒǡ™Š‘†‡˜‡Ž‘’‡†–Š‡
ADVANTAGES Ž‹‹…ƒŽ‰‘Ž†•–ƒ†ƒ”† ‹‰Š•’ƒ–‹ƒŽ”‡•‘Ž—–‹‘
‘Ž†ƒ’‡”‹‡–‡”‹ͳͻͶ͸Ǥ‡†‡ϐ‹‡†•–ƒ†ƒ”†
•‹œ‡•ˆ‘”’‡”‹‡–”‹…•–‹—Ž‹ǡƒ†–Š‡
‘Ž†ƒ•‹œ‡• 20 IV 0.8°
‹‰Š’”‡…‹•‹‘•‡•‹–‹˜‹–›–Š”‡•Š‘Ž†• ƒ•–’‡”‹’Š‡”ƒŽ–‡•–‹‰ –‘ƒ”‡•–‹ŽŽ™‹†‡Ž›—•‡†Ǥƒ…Š•–‡’…‘””‡•’‘†•
–‘ƒ…Šƒ‰‡‹†‹ƒ‡–‡”„›ƒˆƒ…–‘”‘ˆʹƒ†‹ƒ”‡ƒ
Fully automated ”‘˜‹†‡•‹ˆ‘”ƒ–‹‘ƒ„‘—–‘–Š‡”˜‹•—ƒŽˆ—…–‹‘• III 0.43°
„›ƒˆƒ…–‘”‘ˆͶǤ‹œ‡‹••‡˜‡”ƒŽ–‹‡••ƒŽŽ‡”–Šƒ
‹‰ŠŽ›‹–‡”ƒ…–‹˜‡ǡϐŽ‡š‹„Ž‡ƒ†ƒ†ƒ’–ƒ„Ž‡ –Š‡’Š›•‹‘Ž‘‰‹…ƒŽ„Ž‹†•’‘–ƒ†™ƒ•…‘•‹†‡”‡†–‘
„‡ƒƒ……—”ƒ–‡‡ƒ•—”‡‡–•‹œ‡Ǥ
II 0.2°

WHAT IT IS BEST ƒŽŽ…Šƒ‰‡•‹•‡•‹–‹˜‹–›–Š”‡•Š‘Ž†• ƒŽŽ…Šƒ‰‡•‹•’ƒ–‹ƒŽ‡š–‡–‘ˆƒ†‡ˆ‡…–

AT DETECTING
The Goldmann stimulus sizes I to V are presented in I 0.1°
Šƒ‰‡•‹–Š‡…‡–”ƒŽƒ”‡ƒ ‡”‹’Š‡”ƒŽ…Šƒ‰‡•
BOX
relation to the size of the physiological blind spot.
Remaining vision in advanced diseases
Provides expert
COMMON USES
Žƒ—…‘ƒ ‡—”‘Ǧ‘’Š–ŠƒŽ‘Ž‘‰‹…ƒŽ…‘†‹–‹‘•
knowledge
Macular diseases ‡”‹’Š‡”ƒŽ”‡–‹ƒ†‹•‡ƒ•‡•
FUNCTION-SPECIFIC PERIMETRY
Visual ability testing ‘™˜‹•‹‘
—…–‹‘Ǧ•’‡…‹ϐ‹…’‡”‹‡–”›—•‡•†‹ˆˆ‡”‡–•–‹—Ž—•–›’‡• „ƒ…‰”‘—† ȋŠ‘”–Ǧƒ˜‡Ž‡‰–Š —–‘ƒ–‡† ‡”‹‡–”›ǡ
Š‹Ž†”‡
–‘ •–‹—Žƒ–‡ †‹ˆˆ‡”‡– ˜‹•—ƒŽ ˆ—…–‹‘• ȋ‡Ǥ‰Ǥǡ ‘–‹‘ǡ ‘” ‘” ȌǢ ƒ ™Š‹–‡ ϐŽ‹…‡”‹‰ •–‹—Ž—• ‘ ƒ ™Š‹–‡ „ƒ…-
ƒ–‹‡–™‹–Š…‘‰‹–‹˜‡‹’ƒ‹”‡– …‘Ž‘” ˜‹•‹‘Ȍǡ „—– –Š‡› ƒŽŽ Šƒ˜‡ –Š‡ •ƒ‡ ’—”’‘•‡ǣ ‰”‘—†ȋ Ž‹…‡”‡”‹‡–”›ȌǢ‘”ƒ’—Ž•ƒ–‹‰•–‹—Ž—•™‹–Š
‡ƒ•—”‹‰ƒ•—„•‡–‘ˆ–Š‡˜‹•—ƒŽ•›•–‡‹†‹˜‹†—ƒŽŽ›ǡ–‘ …‘…‡–”‹…”‹‰•…Šƒ‰‹‰‹„‘–Š•’ƒ–‹ƒŽ”‡•‘Ž—–‹‘ƒ†
‰‡–‘”‡•‡•‹–‹˜‡”‡•’‘•‡•ˆ‘”‡ƒ”Ž›†‹•‡ƒ•‡†‡–‡…–‹‘Ǥ …‘–”ƒ•–ȋ—Ž•ƒ”‡”‹‡–”›ȌǤŠ‡›ƒ”‡†‡•…”‹„‡†‹‘”‡
‹ˆˆ‡”‡–…–‘’—•’‡”‹‡–‡”‘†‡Ž•‘ˆˆ‡”†‹ˆˆ‡”‡–ˆ—…- †‡–ƒ‹Ž‹Šƒ’–‡”ͳͲǤ
STIMULUS TYPE: STANDARD OR NON-CONVENTIONAL –‹‘Ǧ•’‡…‹ϐ‹…•–‹—Ž‹ȋFIG 4-3Ȍǣƒ„Ž—‡•–‹—Ž—•‘ƒ›‡ŽŽ‘™

STANDARD WHITE-ON-WHITE PERIMETRY

FUNCTION-SPECIFIC PERIMETRY
Š‡ •–ƒ†ƒ”† ’‡”‹‡–”‹… •–‹—Ž—• ‹• ™Š‹–‡ ‘ ƒ ™Š‹–‡ Ž‹‰Š– ƒŽŽ‘™• ˜‹•—ƒŽ ϐ‹‡Ž† –‡•–‹‰ ˆ”‘ ‡ƒ”Ž› –‘ ƒ†˜ƒ…‡†
„ƒ…‰”‘—†ǡƒ†–Š‹•–›’‡‘ˆ’‡”‹‡–”›‹•…‘‘Ž›”‡- †‹•‡ƒ•‡ȋ‹Ǥ‡Ǥǡ‹–‘ˆˆ‡”•ƒŽƒ”‰‡†›ƒ‹…–‡•–‹‰”ƒ‰‡ȌǤ›
ˆ‡””‡†–‘ƒ•™Š‹–‡Ǧ‘Ǧ™Š‹–‡’‡”‹‡–”›ǡ‘”–ƒ†ƒ”†—–‘- …‘˜‡–‹‘ǡ–Š‡•–ƒ†ƒ”†•–‹—Ž—•—•‡†‹•”‘—†ǡ™‹–Šƒ
ƒ–‡†‡”‹‡–”›ȋȌǤ †‹ƒ‡–‡”‘ˆͲǤͶ͵ιǡ™Š‹…Š‹•ƒŽ•‘–Š‡
‘Ž†ƒ•–‹—Ž—•
•‹œ‡ǡ„ƒ•‡†‘–Š‡†‡ϐ‹‹–‹‘‘ˆ”‘ˆ‡••‘”ƒ•
‘Ž†- Time 1 Time 2
Š‡ ™Š‹–‡ …‘Ž‘” •–‹—Ž—• ‘ˆˆ‡”• –Š‡ ƒ†˜ƒ–ƒ‰‡ ‘ˆ •–‹- ƒǤ ‘” ‘”‡ ‹ˆ‘”ƒ–‹‘ ‘
‘Ž†ƒ •–‹—Ž—•
—Žƒ–‹‰ƒŽŽ†‹ˆˆ‡”‡–”‡–‹ƒŽ…‡ŽŽ–›’‡•Ǥ•ƒ”‡•—Ž–ǡ™Š‹–‡ sizes, refer to BOX 4BǤ ON OFF

SWAP Flicker Pulsar

FIGURE
TEXT Illustrates key
FIGURE 4-3 Stimuli used in function-specific perimetry from left to right: Short Wavelength Automated Perimetry (SWAP), Flick-
Full presentation er Perimetry and Pulsar Perimetry.
information in
of a topic an easy to
understand way

FIGURE 1-1 To accommodate the preferences of different readers, different structural elements are used in the Visual Field
Digest. To highlight key information, there are Figures and Tables; to provide a full overview of a topic, there is full text; and to
provide in-depth expert knowledge, there are Boxes.
Content at a glance 3

is of interest to some readers, but not crucial for good fere with the low of the book. The elements described
clinical practice. Such information is provided in a light above are shown in FIG 1-1.
blue box and can be read for interest but does not inter-

CONTENT AT A GLANCE
In this section, a brief overview of the content of each chapter is presented.

CHAPTER 2 – WHAT IS PERIMETRY?

Chapter 2 provides essential information on perimetry provides a general introduction on how the data is dis-
as a technology which is valid for any perimeter brand. played, and highlights common challenges associated
It shows how and why visual ield testing is performed, with visual ield testing.

CHAPTER 3 – HOW TO PERFORM PERIMETRY YOU CAN TRUST

Chapter 3 focuses on information relevant to visual ield falls in perimetry such as learning effects, fatigue effects,
technicians and those people instructing them. It stresses set-up errors and artifacts are presented, along with the
the importance of the visual ield technician in obtaining procedures for avoiding these problems. How to detect
trustworthy visual ield results and explains the essential whether a visual ield is trustworthy is later presented
steps of visual ield testing. In a second part, common pit- in Chapter 8.

CHAPTER 4 – KEY EXAMINATION PARAMETERS

Chapter 4 focuses on ixed examination parameters and The idea is to provide an introduction to what these pa-
the key patient-speciic parameters a clinician needs rameters are and how to make appropriate testing deci-
to decide about. Key questions to be answered regard- sions. The key parameters will be described in depth in
ing patient-speciic test parameters are the following: subsequent chapters.
1) Static or kinetic perimetry? 2) Which stimulus type?
3) Which test pattern? 4) Which strategy?
4 Chapter 1 | Introduction

CHAPTER 5 – SELECTING A TEST PATTERN

Chapter 5 presents all available test patterns on Octo- Performance evaluations such as driving and visual dis-
pus perimeters. The chapter is organized according to ability tests as well as ptosis test patterns are described
pathology or test (i.e., it starts with glaucoma, and con- towards the end of the chapter.
tinues with neuro-ophthalmic and retinal diseases).

CHAPTER 6 – SELECTING A TEST STRATEGY

Chapter 6 presents all available test strategies on Octo- clinician in selecting one of the various quantitative or
pus perimeters and shows that there is always a trade-off qualitative test strategies.
between test duration and accuracy in order to guide the

CHAPTER 7 – OVERVIEW OF VISUAL FIELD REPRESENTATIONS

Chapter 7 introduces all visual ield representations avail- in each representation and further information about the
able on Octopus perimeters and shows their respective design of the representation. For clinicians, this chapter
relationships. Further, each representation is explained in can serve as a glossary.
detail, including a clear deinition of all the symbols used

CHAPTER 8 – CLINICAL INTERPRETATION OF A VISUAL FIELD

Chapter 8 is a key chapter in this book, guiding clinicians Further, this chapter highlights those representations
through visual ield interpretation in an easy to follow most useful in answering speciic clinical questions, and
worklow. It starts by showing six visual ield examples shows how to interpret these representations in clinical
and their respective representations across all stages of practice. Clinical examples are frequently provided to
disease to provide a graphical reference on what visual illustrate the beneits of each respective representation
ield results look like in a given situation. The same cases in a certain clinical situation.
are also provided as a poster that can be removed from
the book as a reference in daily clinical practice.

CHAPTER 9 – INTERPRETATION OF VISUAL FIELD

PROGRESSION
Chapter 9 focuses on the use of EyeSuite Progression determine whether a visual ield series is stable or not.
Analysis to assess visual ield progression. It explains Further, it shows the beneits and interpretation of the
the fundamentals of the trend analysis approach used to various trend representations, including Global Trend
Content at a glance 5

Analysis, Cluster Trend Analysis and Polar Trend Analy- the visual ield in which progression is occurring and, in
sis, which not only allow it to be determined whether a case of glaucoma, where to look for a spatial relationship
visual ield series is progressing and at which rate, but with structural results.
also whether progression is diffuse or local, the area of

CHAPTER 10 – NON-CONVENTIONAL PERIMETRY

Chapter 10 focuses on other stimulus types besides the formation about Pulsar, SWAP and Flicker perimetry. The
standard Goldmann size III used in perimetry. The chap- chapter then concludes with the beneits of using a larger
ter starts with function-speciic perimetry designed for stimulus V for low-vision patients.
early glaucoma detection and provides background in-

CHAPTER 11 – KINETIC PERIMETRY

Chapter 11 focuses on kinetic perimetry. Similar to the presented and illustrated in a real clinical case. Towards
static perimetry chapter, the basic examination parame- the end, the beneits of different levels of automation are
ters and when to choose each one are discussed. Gener- also discussed.
al approaches on how to perform kinetic perimetry are

CHAPTER 12 – TRANSITIONING TO A DIFFERENT PERIMETER

MODEL
Chapter 12 focuses on speciic challenges associated rimeter models and shows the impact of patient-related
with transitioning from one perimeter model to another. luctuation. To support a smooth transition from an HFA
It focuses both on the transition to a different Octopus perimeter to an Octopus perimeter, guidance in relation
model, as well as the transition from a Humphrey to an to known HFA perimeter terminologies is provided on
Octopus model. It highlights the importance of normative the selection of test parameters as well as the interpreta-
databases for minimizing the differences between pe- tion of the perimetric result.

CHAPTER 13 – CLINICAL CASES

To support the interpretation of visual ield results in contain key patient information, as well as visual ield
clinical practice, 23 clinical cases are presented, show- results and other relevant diagnostic results such as IOP,
ing typical visual ields of patients with glaucoma, neu- fundus images, OCT scans and MRIs.
ro-ophthalmic disease and retinal disease. All these cases
 7

CHAPTER 2
WHAT IS PERIMETRY?

INTRODUCTION
PERIMETRY – A STANDARD TEST IN OPHTHALMOLOGY
Perimetry is a standard method used in ophthalmol- nose glaucoma, but it is also often used to assess visu-
ogy and optometry to assess a patient’s visual ield. al loss resulting from retinal diseases, as well as optic
It provides a measure of the patient’s visual function nerve, chiasmal or post-chiasmal damage due to trauma,
throughout their ield of vision. The devices used to per- stroke, compression and tumors.
form this evaluation are called perimeters. Perimetry is
performed for several reasons: 1) detection of pathol- Additionally, perimetry is used regularly for visual ability
ogies; 2) evaluation of disease status; 3) follow-up of testing. Its most common use is to test a person’s visual
pathologies over time to determine progression or dis- ability to drive. Furthermore, it is used to provide a
ease stability; 4) determination of eficacy of treatment quantitative measure of visual function in order to de-
and 5) visual ability testing. termine eligibility for a pension for visual impairment,
and also to assess the beneits of ptosis surgery.
Any pathology along the visual pathway usually results
in a loss of visual function. Perimetry can identify de- In sum, perimetry is a universally available diagnostic
viations from normal, and consequently the associated method to assess a patient’s visual ield or visual function.
pathologies. Perimetry is most commonly used to diag-
8 Chapter 2 | What is perimetry?

THE NORMAL VISUAL FIELD

SPATIAL EXTENT OF THE VISUAL FIELD
The visual ield of a person is deined as the area in nothing can be seen). The extent of the visual ield is an
which a person can see at a given moment relative to essential part of one’s visual function, because a con-
the direction of ixation, without head or eye movement stricted visual ield has a signiicant negative impact on
(i.e., it deines the boundaries of the area beyond which activities of daily living, and as a result on quality of life.

SPATIAL EXTENT OF A NORMAL VISUAL FIELD

A) MONOCULAR VISUAL FIELD SUPERIOR

SUPERIOR

NASAL
(right eye)
(right eye)
NASAL

TEMPORAL
(right eye)
Fixation

TEMPORAL
(right eye)

INFERIOR

INFERIOR

B) BINOCULAR VISUAL FIELD SUPERIOR

SUPERIOR

TEMPORAL
(left eye)
TEMPORAL
(left eye)

TEMPORAL

Fixation
(right eye)

TEMPORAL
(right eye)

INFERIOR

INFERIOR

FIGURE 2-1 The monocular visual field of one eye is limited by the eye socket, nose, brow and cheekbones (A). The binocular
visual field of two eyes overlaps in the central area (B).
T he norm al visual field 9

The visual ield of one eye is called the monocular visual In people with normal vision, the visual ield is binoc-
ield (FIG 2-1A). Its spatial extent in people with normal ular (FIG 2-1B). This means that it contains input from
vision is limited by the facial anatomy of the person, both eyes, with integration and mapping of information
with the eye socket, nose, brow and cheekbones, which from the two eyes, allowing for stereo acuity and depth
outlines the limits of the visual ield. On average, the perception. Visual information in the central 60 degrees
monocular visual ield extends from 60° nasally to ap- of the visual ield is processed by both eyes.
proximately 90° or more temporally, and from approxi-
mately 60° superiorly to 70° inferiorly.

SENSITIVITY TO LIGHT IN THE VISUAL FIELD

The area in which a person can see (extent of the visual level hanging from the ceiling. In that room, only a few
ield) does not sufice to describe a person’s vision. It is people can see. As the light intensity of the bulb is in-
also important to have a measure of sensitivity to light. creased, an increasing number of people will be able to
But what is a person’s sensitivity to light? One can see in the room. The people who could see even the very
imagine a room in which 100 people are present. The dim light bulb have a very high sensitivity to light, while
room is dim, with an adjustable light bulb at its lowest the others have a lower sensitivity to light (FIG 2-2).

SENSITIVITY TO LIGHT
High Dim light

Sensitivity Light
to light intensity

Low Bright light

FIGURE 2-2 This figure illustrates the inverse relationship between light intensity and sensitivity to light. A person who can
perceive a very dim light has a very high sensitivity to light, while a person who can only perceive very bright lights has low
sensitivity to light.
10 Chapter 2 | What is perimetry?

THE HILL OF VISION – A VISUALIZATION OF VISUAL FUNCTION

Sensitivity to light is not uniform across the spatial ex- the X- and Y-axes representing the visual ield locations
tent of the visual ield and depends on location within and the Z-axis representing the sensitivity to light. Since
the visual ield. For normal eyes and in typical daytime this representation resembles a hill, it is commonly re-
illumination, sensitivity is highest in the central area of ferred to as the hill of vision, which is a visualization of
the visual ield and decreases gradually towards the pe- a person’s visual function. Areas within the hill of vision
riphery. To visualize this, sensitivities across the visual represent areas of seeing, and areas outside the hill of vi-
ield can be drawn as a three-dimensional graph, with sion represent areas of non-seeing (FIG 2-3).

HILL OF VISION

Sensitivity
to light

SUPERIOR

Fixation Blind Spot

TEMPORAL
70˚
NASAL

80˚
90˚

INFERIOR

FIGURE 2-3 The hill of vision is a three-dimensional representation of the visual field, with the X- and Y-axes showing the
spatial extent of the visual field using radial coordinates, and the Z-axis showing sensitivity to light. Its name stems from the
fact that normal sensitivity to light is higher at the center than in the periphery, so that normal vision in this representation
resembles a hill.
M easuring sensitivity t o light ac ross the visual field 11

MEASURING SENSITIVITY TO LIGHT

ACROSS THE VISUAL FIELD
PERIMETRY ALLOWS QUANTIFICATION OF ABNORMAL
SENSITIVITY TO LIGHT
Deviations from the normal hill of vision provide valu- can be either constrictions of the boundaries of the visual
able clues regarding visual ield loss and the underlying ield, or depressions of sensitivity. Such depressions can
pathologies. The pattern and shape of visual loss can be be present throughout the visual ield (widespread low-
identiied by investigating deviations from the normal hill ering of sensitivity), or localized in speciic areas of the
of vision. Differences in the visual ield between the two visual ield (scotomas). It is thus desirable to quantify a
eyes can also be identiied by inspecting deviations from patient’s hill of vision with high accuracy and to identify
the normal hill of vision. These deviations from normal its deviation from a normal hill of vision (FIG 2-4).

PERIMETRY ALLOWS DETECTION OF ABNORMAL SENSITIVITY TO LIGHT

Sensitivity
to light

Normal Hill of Vision

Pathological Hill of Vision

FIGURE 2-4 Pathologies affecting sensitivity to light result in an altered hill of vision for the patient. The deviation from the
normal hill of vision provides valuable information regarding the nature and severity of the pathology.
12 Chapter 2 | What is perimetry?

THE PERIMETRIC TEST

Perimetry accurately quantiies a patient’s sensitivity to stimulus anywhere in their visual ield by pressing a re-
light throughout the visual ield in a systematic, highly sponse button. Conceptually and to simplify things, one
standardized manner. To assess the visual ield, a hemi- can imagine that at the irst location the luminance of
spheric cupola is typically used to project small light the stimulus is increased from the “off” position to the
stimuli across the entire area of the visual ield. These dimmest level of an adjustable light bulb. If the patient
stimuli, and the uniform background onto which the cannot see the stimulus when it is off or very dim, anoth-
stimuli are projected, are highly standardized in terms of er stimulus is shown later, at a higher level of light inten-
shape, size, color, light intensity and duration, to ensure sity. Once the stimulus reaches a certain light intensity,
high reproducibility. The most commonly used test con- the patient can see it and presses the button. It should
ditions project a round, white stimulus on a background, be noted that the stimulus is always turned off before the
which is also white, but dimmer than the stimulus. The next stimulus is presented.
luminance (i.e., the relected light intensity) of the stim-
ulus can be altered from very low to very high. More This minimum light intensity that can be seen deines the
detailed information on key examination parameters is patient’s sensitivity to light (i.e., the threshold between
provided in Chapter 4. non-seeing and seeing) (FIG 2-5). Due to this evaluation
method, in perimetry the word threshold is often used,
To perform a perimetric test, patients are asked to sit instead of sensitivity to light. For ease of understanding,
in front of the cupola with their head stabilized, to ix- “sensitivity threshold” is the term used throughout
ate onto a target in the center, and to indicate seeing a this book.

SENSITIVITY THRESHOLDS

Dim = Seen
Stimulus
= Not seen
No
Do you see
the stimulus?
No
THRESHOLD
SENSITIVITY

No

Fixation Yes

Yes

Yes

Stimulus Yes

Bright
Stimulus

FIGURE 2-5 The sensitivity threshold between seeing and non-seeing for stimuli of different intensity presented against a fixed
background illumination at a given location in the visual field provides one data point on the hill of vision.
M easuring sensitivity t o light ac ross the visual field 13

The sensitivity threshold at the irst test location provides across the visual field ( FIG 2-6B). By connecting the
the irst data point to characterize the hill of vision (FIG sensitivity thresholds at all tested locations, a patient’s
2-6A). To determine the patient’s hill of vision, the afore- hill of vision can be drawn (FIG 2-6C).
mentioned procedure is then repeated at many locations

DRAWING THE HILL OF VISION FROM THE SENSITIVITY THRESHOLDS

A) SENSITIVITY THRESHOLD OF FIRST LOCATION

Do you see
the stimulus? Sensitivity threshold
of first location
Sensitivity
threshold

Fixation

Stimulus

B) SENSITIVITY THRESHOLDS AT DIFFERENT LOCATIONS

Sensitivity thresholds
at all tested locations
Stimulus
Sensitivity
threshold

Do you see here?

Fixation

Do you see there?

C) SENSITIVITY THRESHOLDS AT ALL TESTED LOCATIONS

Sensitivity thresholds
Stimulus at all tested locations
Sensitivity
threshold

Do you see here?

Fixation

Do you see there?

FIGURE 2-6 The hill of vision can be drawn from the individually determined sensitivity thresholds at each location.
14 Chapter 2 | What is perimetry?

While the process used to determine sensitivity thresh- perimetry and they will be discussed in depth in Chapters 4,
olds is easy to understand, it would be much too time-con- 5 and 6. Additionally, the order of stimulus presentation is
suming to test each location of the hill of vision in this randomized throughout the visual ield, to avoid patients
manner. Therefore, more eficient strategies are used in becoming accustomed to a certain presentation pattern.

DISPLAY OF SENSITIVITY
THRESHOLDS
THE DECIBEL SCALE USED IN PERIMETRY
In clinical practice, visual ield information needs to be perimetric stimulus that the device can display, whereas
easy to interpret and should directly correspond to the values close to 32 dB represent normal foveal vision for
clinical situation. For that purpose, perimetry employs a 20-year-old person. While the decibel scale is intuitive
the decibel scale, with its unit of measurement being to understand and use in clinical practice, the underlying
the decibel (dB). The decibel range depends on perim- considerations and formulas are less intuitive and of lim-
eter type and typically ranges from 0 dB to approxi- ited relevance for clinical practice. For those interested,
mately 32 dB in the fovea. A sensitivity threshold of 0 dB they are explained in BOX 2A.
means that a patient is not able to see the most intense

BOX 2A THE RATIONALE FOR THE USE OF THE DECIBEL SCALE

The intensity of the light that is relected on the perimetric surface is called luminance and can be
measured objectively with a light meter. It is expressed in candelas per meter squared (cd/m) or in the
older unit, the apostilb (asb), with 1 cd/m corresponding to 3.14 asb. The measurement indicates light
lux per unit area.
In theory, sensitivity thresholds could be expressed in luminance units. While this would be correct, it
would be impractical in clinical practice for the following reasons:

1. Large number of discrete luminance levels

The human eye can adjust to a large range of luminance levels over at least 3-4 orders of magnitude
(e.g., from almost 0 asb to 10,000 asb in normal daytime lighting conditions). This would make
certain threshold values very large and impractical to display.
2. The relationship between visual function and luminance is not linear
Visual function is not linear with regard to the light intensity levels. For example, while an increase
of 90 asb is likely to be noticed when luminance is increased from 10 to 100 asb, this same absolute
increase in luminance (90 asb) would hardly be noticeable when luminance is increased from 1,000
to 1,090 asb.
3. Inverse relationship between luminance and sensitivity to light
There is an inverse relationship between stimulus luminance and a patient’s sensitivity to light.
A patient with high sensitivity to light only needs a stimulus with low luminance to be able to see
it, while a patient with low sensitivity to light needs a stimulus with high luminance. For clinical
Display of sensitivity thresholds 15

use, a scale deining visual ield loss as low and good vision as high would be more intuitive than
the inverse luminance scale.

4. Lack of definition of complete visual field loss

Since luminance and sensitivity to light are inversely related, complete visual ield loss would be
a very high luminance number. This number would be limited by the maximum stimulus the peri-
meter is able to display, potentially resulting in large differences between different perimeter models.

THE DEFINITION OF SENSITIVITY TO LIGHT USING THE DECIBEL SCALE

The decibel scale addresses all of these issues and uses luminance levels solely as input variables. The
relationship between the decibel scale and the luminance scale in apostilbs is shown below.

RELATIONSHIP BETWEEN SENSITIVITY TO LIGHT AND LUMINANCE

SENSITIVITY TO LIGHT STIMULUS LUMINANCE

(SENSITIVITY THRESHOLD)
Decibels (dB) Apostilb (asb)

40 0.4

Foveal normal ~32.8 dB

sensitivity for 30 4.0
20-year-old
person
20 40

10 400

0 4,000

The decibel scale is used to express sensitivity to light. This igure shows the relationship between
sensitivity to light and luminance. The maximum stimulus brightness, which is used as a default in
recent Octopus perimeter models, is 4,000 asb. It is a logarithmic scale and is inversely related to
the linear luminance scale in apostilbs (asb). Note that the maximum stimulus brightness might be
different in different perimeter models.

The sensitivity to light in decibels is deined using the formula below

dB = 10 * log (Lmax/L)
where dB is the sensitivity threshold, Lmax is the maximum luminance the perimeter can display, and L
is the luminance of the stimulus at the threshold (both expressed in apostilbs).
The logarithmic scale is used to address the large range of luminance values and to relate this range
more linearly to visual function. To address the inverse relationship between luminance and sensitivity
to light, the inverse of luminance (1/L) is used in the formula; and to make sure that near complete
visual ield loss equals 0 dB, which is intuitive, the maximum stimulus luminance Lmax is added to the
equation.
Since 0 dB refers to the maximum intensity that the perimeter can produce, its interpretation in terms
of stimulus luminance may be different for various visual ield devices. This should be kept in mind
when switching between different perimeter models. Chapter 12 will focus on how to deal with
differences between perimeters in clinical practice.
16 Chapter 2 | What is perimetry?

GRAPHIC DISPLAY OF SENSITIVITY THRESHOLDS

The three-dimensional hill of vision contains large function from the three-dimensional representation.
amounts of information. It may therefore be challenging Cartographers face similar challenges when displaying
to appropriately display all aspects of a patient’s visual three-dimensional mountains or hills, and have used

GRAPHIC DISPLAY OF SENSITIVITY THRESHOLDS

MOUNTAIN – Geographical display HILL OF VISION – Perimetric display OCTOPUS REPRESENTATIONS

3D map 3D map

No 3D map available
on Octopus perimeters

Numerical altitude map Numerical sensitivity threshold map Values

27

0m 600m 10 dB 28 28 28
0m 10 dB
1200m 30
0m 1800m 20 dB 10 dB
31 30
1200m 2400m 26 29
600m 1200m 3000m 1800m 20 dB 31 30 27 27
2400m 30 dB 20 dB 33 32
3000m 2400m 3600m 600m 30 dB 28 31 31 31
1800m 1800m 3000m 2400m 10 dB 28 31 31 30 27 25
1800m 10 dB
0m 2400m 1800m 20 dB 27 21 29 33 29
600m 1200m 1200m 29 28 30 28
10 dB 31 29
0m 600m 0m
10 dB 26 29 27 25 27 26

29 26

Color altitude map Color sensitivity threshold map Grayscale of Values

Altitude lines map Sensitivity threshold lines map Kinetic Perimetry

10 30 40 50 60 70 80 90

FIGURE 2-7 As in cartography, there are different ways to display the three-dimensional hill of vision in two dimensions.
Sampled altitude levels can be displayed numerically, a color code can be used to represent different altitude levels, or altitude
lines can show the different altitude levels.
Challenges in visual field testing and interpretation 17

two-dimensional maps as a solution. Similar display provide a good representation of a hill on a map. For
strategies are used to display the hill of vision in two perimetry, these lines of equal altitude are referred to as
dimensions. isopters (lines of equal sensitivity).

As in geographical maps (FIG 2-7), the various sensitivity It should be noted that whichever display form is used,
thresholds can be displayed numerically (i.e., by sam- there is always some information lost. All three versions
pling certain altitudes to give a feel for the overall shape are used to display perimetric results, as each emphasizes
of the hill or mountain). Color codes for different altitude different clinical information. For more details of the
levels are also often presented on geographical maps. various representations, see Chapters 7, 8, and 11.
Last but not least, lines of the same altitude level can

CHALLENGES IN VISUAL FIELD

TESTING AND INTERPRETATION
PERIMETRIC TESTING HAS LOW RESOLUTION
So far, this book has presented perimetry as a very accu- From a practical point of view, however, it is nearly
rate way of continuously showing the stimuli of increasing impossible to test each location within the visual ield
intensity for the patient. It has also been assumed that (spatial resolution) using each possible light intensity
thresholding is performed at all locations across the (luminance resolution). This would take too long to be
visual ield. useful in a clinical setting. Therefore, referring back to

IDEAL VERSUS PRACTICAL PERIMETRIC TESTING

SPATIAL RESOLUTION RESOLUTION OF

SENSITIVITY THRESHOLDS
Ideal Practical Ideal Practical
90 90

180 0 180 0

270 270

FIGURE 2-8 Ideally, the hill of vision would be drawn from an infinite number of test locations and from a continuously
changing stimulus luminance. In reality, the time constraints do not allow for this kind of testing, and only sampling at some
locations and some luminance levels is possible.
18 Chapter 2 | What is perimetry?

the example of the light bulb in a room, the dimmer only ber of light intensity levels are presented. This approach
has a set number of discrete levels, such as high, medi- introduces inaccuracies in the perimetric test. In order to
um and low, and there are only a few bulbs to illuminate still be able to receive the information necessary for good
the room (FIG 2-8). clinical decision-making, a number of elaborate process-
es are used in perimetry. This maximizes clinical infor-
For perimetry, this means that stimuli are presented at a mation and offers a good trade-off between testing time
ixed number of key locations and that only a limited num- and accuracy. These are described in Chapters 4, 5 and 6.

NORMAL SENSITIVITIES DEPEND ON AGE AND TEST

LOCATION
As already illustrated in the section about the hill of For these reasons, sensitivity thresholds are challenging
vision, normal sensitivity thresholds depend on the to interpret directly in the clinic, because the representations
test location and are higher at the center than in the pe- of normal and abnormal values depend on testing- and
riphery. In addition, the normal hill of vision is affected patient-speciic factors. For correct clinical assessment
by age. Normal sensitivity to light in decibels decreases of sensitivity thresholds, a clinician would have to keep
approximately linearly with increasing age, beginning at normal reference values in mind for all age groups and
the age of 20.1-3 Thus, the hill of vision of a 20-year-old test locations, in order to correctly interpret the results.
is typically higher than the hill of vision of an 85-year-old That would be a challenging task.
person (FIG 2-9).

HILL OF VISION IS AGE- AND LOCATION-DEPENDENT

Sensitivity
threshold

20-year-old

85-year-old

FIGURE 2-9 The normal hill of vision shows the highest sensitivity thresholds at the center, with decreasing sensitivity thresh-
olds towards the periphery. Similarly, there is also a decrease in sensitivity thresholds with increasing age at all test locations.
Challenges in visual field testing and interpretation 19

Therefore, distinct normative databases have been devel- to the respective normative value for someone of that
oped for most modern perimeters and these databases age. The calculated Comparisons to normal are clinically
are used to facilitate clinical visual ield interpretation. meaningful, as they relate directly to sensitivity loss (FIG
Normative databases contain normal reference values 2-10). Alternative expressions that are commonly used
for each age group and test location (BOX 2B). They are are deviation from normal or defect.
used to compare any measured sensitivity threshold

COMPARISONS SHOW THE DEVIATION FROM NORMAL

NORMATIVE VALUES (MEASURED) VALUES COMPARISONS (TO NORMAL)

Normal sensitivity threshold - Measured sensitivity threshold = Sensitivity loss

Sensitivity
threshold
Comparisons

Normative Values
of 20-year-olds

Measured Values
of a 20-year-old

FIGURE 2-10 The difference between a normal and a measured visual field point is commonly called ‘Comparison to
normal’ (also referred to as deviation from normal or defect) and its interpretation is independent of a patient’s age or the
visual field location.

Due to their ease of use, most representations in the normal and not on the measured sensitivity thresholds.
Octopus perimeters are based on the Comparisons to For more information, refer to Chapter 7.
20 Chapter 2 | What is perimetry?

BOX 2B NORMATIVE DATABASES IN OCTOPUS PERIMETERS

DESIGN OF A NORMATIVE DATABASE

By deinition, the normative database of a perimeter consists of a pool of visual ield data from people
with normal vision in all age groups. The challenge associated with generating this pool is to ensure
that these normal visual ields are truly normal and that there are suficient visual ields to account for
individual differences.
The standards to be fulilled for a perimetric normative database are described exhaustively in the
ISO norm «Ophthalmic instruments - Perimeters (ISO 12866:1999/Amd1:2008); Amendment A1,
Appendix C». All normative databases of Octopus perimeters comply fully with these standards. The
typical process to comply with the standards is to perform a clinical study that includes a thorough eye
examination and repeated visual ield testing.

DISTINCT NORMATIVE DATABASES FOR DIFFERENT DEVICES AND EXAMINATION PARAMETERS

Since particular perimeter models vary in design and might use different examination parameters,
a stimulus of the same light intensity may be perceived differently on various perimeter models.
Therefore, there are distinct normative databases for different perimeter types and settings.

PERIMETRY HAS OBJECTIVE AND SUBJECTIVE

COMPONENTS
In the interest of simplicity, perimetry has been treated as patient does not understand the test, does not pay atten-
a purely objective procedure, with exact measurements tion or does not focus continuously on the central target,
and distinct sensitivity thresholds at each test location. then the results of the test will be dificult to interpret.
This is true for the equipment and the test conditions. Additionally, some patients may be very conservative in
However, there is a subjective element to perimetry, due their judgements, requiring a more intense stimulus for
to the subjectivity of the patients undergoing the test. detection, while other patients may be liberal and accept
As a result, there is always a certain amount of normal a less intense stimulus for detection. The most important
luctuation both among different normal individuals, as person to maximize the performance of the patients is the
well as between different measurements of the same visual ield examiner (e.g., a perimetrist or technician).
individual over a short period of time. The accuracy of Chapter 3 focuses on potential sources of unreliable and
the test results is highly dependent on several factors, thereby highly luctuating visual ields and provides prac-
including the cooperation of the patients, their cognitive tical guidance on how to minimize these factors.
and physical abilities, and their decision criteria.4-6 If the

NORMAL FLUCTUATION DEPENDS ON TEST LOCATIONS

AND DISEASE SEVERITY
A further complication in visual ield interpretation is the tion is smaller at the center of the visual ield than in the
fact that normal luctuation is not uniformly distributed periphery and is also smaller in areas of good vision than
across the visual ield (FIG 2-11). Instead, normal luctua- in areas of poor vision.1,7
Challenges in visual field testing and interpretation 21

NORMAL FLUCTUATION IN PERIMETRY

Sensitivity
threshold

Average Hill of Vision

Abnormal

Normal fluctuation

FIGURE 2-11 Since perimetry contains a subjective, patient-related component, there is always normal fluctuation. Its magnitude
depends on both the test location and disease severity.

These two factors must be kept in mind when making measure luctuation around a sensitivity threshold, the
clinical decisions based on visual ield results. To objectively frequency-of-seeing (FOS) curve may be used (BOX 2C).

THE FREQUENCY-OF-SEEING (FOS) CURVE BOX 2C

Due to luctuation, distinct sensitivity thresholds at a given test location cannot be measured precisely.
In reality, the same patient always shows slightly varying responses in repetitive testing. In other words,
the likelihood of seeing or not seeing a stimulus is probabilistic.
As the luminance (i.e., the light intensity of the stimulus) increases, there is a gradual increase from
“unseen” to “seen” responses, so that the probability that a patient will perceive a stimulus changes
gradually from 0% to 100%. Because of this, sensitivity thresholds are deined as the stimulus
luminance that is perceived with a probability of 50%.
To get a measure of luctuation, one can show a stimulus of a certain luminance to a patient many times
at a given test location and determine how often the patient is able to see it. The probability of perceiving
a stimulus can be mapped in a graph as a function of stimulus luminance. When doing this for many dif-
ferent luminance levels, one can generate a frequency-of-seeing (FOS) curve, which describes the prob-
ability that a patient will perceive a target as a function of stimulus luminance. This is a useful tool to
illustrate the variability associated with the determination of thresholds.⁸ In areas of normal sensitivity,
the FOS curve is typically steep, indicating that there is less variability. In other words, the patient has a
high probability of seeing stimuli that are slightly more intense than the luminance at the threshold, and
also a high probability of not seeing stimuli that are slightly less intense than those at the threshold. This
is illustrated on the left side of the igure by the steep shape of the FOS curve.
In areas where defects are present, the FOS curve is typically shallow, indicating that there is greater
variability. In other words, there is a gradual change in the probability of detecting stimuli that are higher
and lower than the luminance at threshold. This is illustrated on the right side of the igure by the shallow
shape of the FOS curve.
22 Chapter 2 | What is perimetry?

FREQUENCY-OF-SEEING (FOS) CURVE

Fluctuation Fluctuation
100%
Probability of seeing the stimulus

Normal Abnormal
sensitivity sensitivity
threshold threshold

50%

0%

Dim stimulus Bright stimulus

The frequency-of-seeing curve provides the scientiic deinition of a light sensitivity threshold while
taking luctuation into account. It shows the probability of a patient perceiving a certain stimulus
luminance. The light sensitivity threshold is deined as the stimulus luminance that the patient can
see 50% of the time. Fluctuation is quantiied as the range of luminance at which the probability of
seeing the stimulus is 0% to the luminance at which the probability of seeing the stimulus is 100%.

CLINICAL STANDARD FOR VISUAL FUNCTION TESTING

Even though perimetry has low resolution and contains daily living, which are the most important factors for the
subjective, patient-related components resulting in normal patient. Additionally, slowly progressing diseases such as
luctuation, perimetric testing is useful to assess visual glaucoma can be followed accurately through all stages
ields in clinical practice. It remains highly important be- of the disease. Perimetry is therefore an indispensable
cause visual ield function is most directly related to a tool for every glaucoma specialist.
patient’s quality of life and ability to perform activities of
References 23

REFERENCES
1. Zulauf M. Normal visual ields measured with Octopus Program G1. I. Differential light sensitivity at individual test
locations. Graefes Arch Clin Exp Ophthalmol. 1994;232:509-515.
2. Zulauf M, LeBlanc RP, Flammer J. Normal visual ields measured with Octopus-Program G1. II. Global visual ield indices.
Graefes Arch Clin Exp Ophthalmol. 1994;232:516-522.
3. Haas A, Flammer J, Schneider U. Inluence of age on the visual ields of normal subjects. Am J Ophthalmol. 1986;101:
199-203.
4. Flammer J, Drance SM, Fankhauser F, Augustiny L. Differential light threshold in automated static perimetry. Factors
inluencing short-term luctuation. Arch Ophthalmol. 1984;102:876-879.
5. Flammer J, Niesel P. Reproducibility of perimetric study results. Klin Monbl Augenheilkd. 1984;184:374-376.
6. Stewart WC, Hunt HH. Threshold variation in automated perimetry. Surv Ophthalmol. 1993;37:353-361.
7. Wall M, Woodward KR, Doyle CK, Artes PH. Repeatability of automated perimetry: a comparison between standard
automated perimetry with stimulus size III and V, matrix, and motion perimetry. Invest Ophthalmol Vis Sci. 2009;50:
974-979.
8. Chauhan BC, Tompkins JD, LeBlanc RP, McCormick TA. Characteristics of frequency-of-seeing curves in normal subjects,
patients with suspected glaucoma, and patients with glaucoma. Invest Ophthalmol Vis Sci. 1993;34:3534-3540.
 25

CHAPTER 3
HOW TO PERFORM PERIMETRY
YOU CAN TRUST

INTRODUCTION
PERIMETRY – A SUBJECTIVE TEST
Perimetry is an elaborate test that depends, to a great In view of the relatively high occurrence of untrust-
extent, on subjective factors such as the patient’s cooper- worthy visual ields, it is extremely important to make
ation and comfort, as well as on using the correct patient sure that the time invested in perimetry is well spent,
information and set-up. Due to this subjective compo- because poorly performed perimetric tests have hardly
nent, untrustworthy visual ield tests are common. The any diagnostic value. It therefore pays to take the time
extent of untrustworthy results largely depends on how and care necessary to obtain trustworthy results by fol-
well perimetry is performed in clinical practice and has lowing certain rules to avoid the most common pitfalls.
been reported to range from 3% to 29% of all visual
ield tests performed.¹-⁵
26 Chapter 3 | How to perform perimetry you can trust

PERIMETRY – NEED FOR A TEAM APPROACH

Three key players are involved in perimetry: the patient, FIG 3-1 shows how each member of the team can contrib-
the examiner and the eye doctor. All three should work ute. When this approach is successfully implemented,
collaboratively to obtain optimal perimetric test results. perimetry can be performed in a positive atmosphere.

PERIMETRY REQUIRES A TEAM APPROACH

PATIENT
st
te
e Ex
th
ure

pr
of

ed

As eed
es
oc
e

pr t
nc

sn
kq
tes Pr
ng the Pr o
rta

ue
o

vi e en
i
po

st

stio break
t
rm ou etry
de
P
te

vi

for
th ro
e im

importan estio rfo

b im d

cle
the

ns
er r
of a

a
Ask qu o pe

vid gho

ar
ce ns

ou
e th

p
with

e s ut th

cou
inst
dt
Emphasiz

upe e test

rage
Be motivate
Collaborate

ruction
rvision
ment
s

EX
AM
OR
CT Pr
ov
IN
ER
DO ide ing
adequate train
All
Pr ow to
ov ne t i me
ide focus cessary etry
on perim on
rec
ogni iati
tion and apprec

Perf ll
orm perimetric test we
Ma Accuracy in entering data ance
ke n
otes ab rform
out patient pe

FIGURE 3-1 In perimetry, it is essential that doctors, examiners and patients have a positive attitude towards perimetry and that
each member of the team contributes to achieving optimum results.

THE IMPORTANT ROLE OF THE DOCTOR

THE DOCTOR-PATIENT RELATIONSHIP

Patients who understand why perimetry is needed and and trust they establish with their patients, doctors are
its importance to their eye care are likely to be more moti- in the best position to convey the importance of perimetry
vated to undergo a perimetric test. Due to the relationship to their patients.
Introduction 27

THE DOCTOR-EXAMINER RELATIONSHIP

Eye doctors should also clearly convey the importance of this goal, the doctor must provide training and give feed-
perimetry to the visual ield examiners who work with back to the examiners. It is also crucial for the doctor to
them in the clinic. For example, the doctor is responsible have reasonable expectations in terms of the time required
for ensuring that the visual ield examiners understand to perform trustworthy perimetric tests. Doctors should
the importance of trustworthy perimetric results to the arrange for their visual ield examiners to be able to dedi-
clinical decision-making process. The visual ield examin- cate time exclusively to performing perimetric tests. This
ers should know that the doctor has a genuine interest in means that they should be free of other tasks that might
building their perimetric knowledge and skills. Towards reduce the examiner’s focus on the patient.

THE IMPORTANT ROLE OF THE VISUAL FIELD EXAMINER

The visual ield examiner is in a unique position to have setting up the perimeter, they also directly oversee the
an impact on the quality of the perimetric results in two patient during the test.
ways. Not only are examiners responsible for correctly

ROLE IN CORRECTLY SETTING UP THE PERIMETER

The visual ield examiner is responsible for entering in performing this aspect of perimetry can significantly
the correct patient information in the perimeter. This is reduce the number of untrustworthy tests and inter-
crucial because this information has a direct impact on pretation errors. The examiner is also responsible for
whether the results of the test can be trusted. Diligence ensuring that an adequate refractive lens is used.

THE EXAMINER-PATIENT RELATIONSHIP

A crucial role of the visual ield examiner is to ensure patient. Additionally, the patient should be encouraged
that the patients perform perimetry to the very best of to communicate to the examiner any dificulties or prob-
their capacity each time they take a test. To give their best lems encountered, and when a brief rest period would be
performance, patients need to be comfortably positioned beneicial.
at the perimeter, they need to know what is expected of
them, and they need to understand how to perform the There is more, however, to the role of a visual ield exam-
test. A competent examiner will ensure that the patient iner. Outstanding examiners will have taken perimetric
is not only correctly positioned, but also comfortable. tests themselves and will understand how the patient
Similarly, a good examiner will convey what is expected feels during the test. This compassionate approach will
of the patient and will give clear instructions on how to go a long way in ensuring patient cooperation and will
perform the test. The examiner can also provide brief rest allow the examiner to give genuine encouragement to the
periods by pausing the test if this will be helpful to the patient when needed during the test.
28 Chapter 3 | How to perform perimetry you can trust

HOW TO PERFORM
VISUAL FIELD TESTING
SETTING UP THE PERIMETER
Perimetry should be performed in a distraction-free room, opaque curtains around the perimeter and earmuffs
environment, to enable the patient to concentrate on offer a cost-effective alternative.
the perimetric test (FIG 3-2). The room should be quiet,
with no activity distracting the patient, and should be at The perimeter is automatically calibrated each time it is
a comfortable room temperature. The cupola should be turned on. It is important for the calibration to take place
kept clean and free of dust and particles. Additionally, the in the same lighting conditions as those used during peri-
room should be dimly lit, to prevent stray light from in- metric testing. Calibration can take up to two minutes and
luencing the perimetric result. A dimly-lit environment should be performed prior to testing patients. Thus, the
is essential when a cupola perimeter, such as the Octopus perimeter should be turned on prior to the patient visit.
900 is used, but is also helpful for non-cupola perimeters.
Ideally, patient data (date of birth, refraction, etc.) are
Ideally, perimetry should be performed in a room dedi- entered before the patient enters the room. If an electronic
cated solely to this purpose. However, if the layout of the medical record system is in use, it will automatically pop-
clinical practice does not offer a stand-alone perimetry ulate the information to the perimeter.

PERIMETER SET UP
Light Heat
Noise Cold

FIGURE 3-2 A perimeter should be set up in a distraction-free, dimly-lit environment.

H ow to perf orm visual field testing 2 9

PLACING AN ADEQUATE TRIAL LENS

The trial lens calculator is helpful in determining the than one trial lens is used, the spherical correction should
adequate spherical and cylindrical trial lenses, based on be placed closest to the patient’s eye. Special attention
the patient’s current refraction and age. It is vital to en- should be given to the orientation of cylindrical lenses,
sure that the patient’s refractive data is up-to-date and it which should be oriented in the angle of the astigmatism
is best practice to determine this prior to each test. The (FIG 3-3).
correct trial lens should be put into the trial lens holder
prior to seating the patient. Trial lenses with a narrow To conirm that adequate refraction is used, the examiner
metal rim should be used, to prevent the rim of the should position the patient and ask whether the ixation
trial lens from blocking the patient’s ield of view. If more target is clearly visible.

PLACEMENT OF CYLINDRICAL TRIAL LENSES

30°

180° 0°

150° 30°

120° 60°
90°

FIGURE 3-3 Placement of a cylindrical lens for a patient with a cylindrical correction of 30°, seen from the examiner’s perspective.

INSTRUCTING THE PATIENT

Due to the subjective components involved in perimetry, 3-4). It can be helpful for examiners to take a perimetry
careful patient instruction is fundamental to achieving test themselves, in order to gain a better understanding
trustworthy results. Patients will be able to cooperate of what patients are experiencing.
more effectively and produce more consistent results if
they understand what is expected of them and why the It is fundamental to ensure that the patients know that
test is being performed. they are not expected to see all stimuli and that some-
times no stimuli are presented. This will help to reduce
The visual ield examiner should therefore take the time some of the potential anxiety experienced by patients,
to explain the aim of the test, what the patient should ex- who should also know that they can pause the test if they
pect to see, and what the patient is expected to do (FIG experience fatigue or have questions.
30 Chapter 3 | How to perform perimetry you can trust

STEP-BY-STEP PATIENT INSTRUCTIONS

1. Perimetry tests your central and peripheral vision.

2. Be relatively still once positioned.

3. Always look straight ahead at the fixation target.

Do not look around the bowl for stimuli.

4. Press the response button whenever you see the stimulus.

a. The stimulus is a flash of light.
b. Only one stimulus is presented at a time.
c. The stimulus might appear anywhere.
d. Some stimuli are very bright, some are very dim,
and sometimes no stimulus is presented.
e. You are not expected to see all stimuli.
f. Do not worry about making mistakes.

5. Blink regularly to avoid discomfort.

a. Don’t worry about missing a point, the device does not
measure while you blink.

6. If you feel uncomfortable or are getting tired

a. Close your eye for a moment, the test will automatically stop.
b. The test will resume once you open your eye.

7. If you have a question

a. Keep the response button pressed; this will pause the test.

FIGURE 3-4 Proper instructions to the patient are essential for the patient to understand their task and consequently to
perform perimetry well. The sequence of instructions listed in this Figure can be used.
H ow to perf orm visual field testing 3 1

SETTING UP AND POSITIONING THE PATIENT

Trustworthy and accurate perimetric results are more tient is correctly positioned and that the non-tested eye
likely to be obtained when the patient is comfortable is covered. The optimum ways to ensure patient comfort
during the test. It is also important to ensure that the pa- and correct alignment will be discussed in this section.

CORRECT EYE PATCH POSITION

Before fully positioning the patient, the eye not being test- for the tested eye. If an adhesive eye patch is used, it is
ed should be covered with an eye patch that allows the important to make sure that it adheres well all around
patient to blink freely (FIG 3-5). If the eye patch is main- the eye. All eye patches should be translucent, to avoid
tained in place with a cord, it is important to ensure that adaptation to the dark by the untested eye, which would
the cord does not obstruct the patient’s ield of view alter the results of subsequent testing of that eye.⁶

EYE-PATCH POSITION

CORRECT INCORRECT
Unobstructed view of test eye Cord obstructs view of test eye

FIGURE 3-5 An eye patch should cover the eye that is not being tested. It should be positioned so as to not obstruct the
patient’s vision in the tested eye.

CORRECT PATIENT POSITION

The patient should be seated in a comfortable position patient is comfortable. Different Octopus models offer
that can be easily maintained throughout the test. A different types of positioning: the Octopus 900 offers a
height-adjustable chair with a backrest and, if available, straight-upright patient position and the Octopus 600
armrests should therefore be used. The perimeter should offers a forward-leaning position.
be placed on a height-adjustable table to ensure that the
32 Chapter 3 | How to perform perimetry you can trust

STRAIGHT-UPRIGHT POSITION

FIGURE 3-6 This drawing illustrates the correct straight-upright patient position recommended for the Octopus 900 and older
Octopus models.

For the Octopus 900 and all older Octopus models, the pa- his or her chin on the chin rest and forehead on the head-
tient should sit as close as possible to the device. Then the rest (FIG 3-6). It is important to ensure that the patient
height of the table should be adjusted until the patient’s maintains direct contact with the device throughout
forehead touches the headrest. The patient should place testing.

FORWARD-LEANING POSITION

1. PREPARATION 2. FINAL POSITION

Headrest 20cm/8 inches

FIGURE 3-7 This drawing illustrates the correct forward-leaning patient position recommended for the Octopus 600.

For the Octopus 600, the patient is positioned in a for- headrest, to allow enough space to lean forward. By
ward-leaning and downward-gazing position (FIG 3-7). inclining from this position, the patient is automatically
The correct position is obtained by irst seating the pa- positioned at the correct height. The patient’s head leans
tient in an upright position at a distance of approximately in fully onto the headrest, providing stable ixation.
20cm/8 inches, with the eyes at the upper level of the
H ow to perf orm visual field testing 3 3

CORRECT EYE POSITION

Once the patient is correctly positioned in the device, it lens. However, the lens should not touch the eyelashes,
is important to ensure that the eye is also correctly po- allowing the patient to blink freely and avoiding the lens
sitioned. Overall, the eye should be well-aligned with the being smeared with make-up.
ixation target and should be relatively close to the trial

CORRECT PUPIL POSITION

CORRECT INCORRECT
Central pupil position Off-center pupil position

FIGURE 3-8 The left-hand panel shows an eye in the video monitor that is correctly positioned, with the cross-hair target locat-
ed within the boundaries of the pupil. The right-hand panel shows an eye that is incorrectly positioned, with the cross-hair target
located outside the boundaries of the pupil.

The Octopus perimeters provide a video monitor so that monitor. The patient is correctly positioned when the
the examiner can see the patient’s eye. When the patient cross-hair target is within the boundaries of the pupil
looks straight at the ixation target, the pupil should be (FIG 3-8). The position of the pupil can be adjusted by
aligned with the cross-hair target provided on the video changing the position of the chin rest.

CORRECT TRIAL LENS POSITION

CORRECT INCORRECT CORRECT INCORRECT

Trial lens close to eye Trial lens too far away Central pupil position Off-center pupil position

FIGURE 3-9 The patient’s eye should be positioned in the center of the trial lens and as close as possible without touching it.

It is important for the patient’s eye to be as close as pos- patient is positioned too far away from the trial lens (FIG
sible to the trial lens, in order to avoid the typical “ring” 3-9). The eyelashes should not touch the lens, however.
defect (i.e., trial lens rim artifact) that occurs when the
34 Chapter 3 | How to perform perimetry you can trust

When a visual ield test assesses both the central and the in order to avoid trial lens rim artifacts. Also, visual itness
peripheral visual ields, it will be necessary to remove the to drive is assessed binocularly (both eyes open). In this
trial lens for the part of the test that covers the periphery, case, no trial lens should be used.

CORRECT FIXATION

It is essential for patients to maintain steady ixation target is not recommended for the G, M, N and D patterns
throughout the test. The Octopus perimeters offer three (see Chapter 5) and for any pattern where the foveal
different ixation targets (FIG 3-10) to promote steady ix- threshold function is turned on.
ation in as many patients as possible. Most patients will
be able to maintain ixation using the standard cross Finally, some patients with severe visual ield loss in the
mark ixation target. If patients have dificulty under- macula region may not be able to see the standard cross
standing where to look when the cross mark ixation mark ixation target. In these patients, the use of the larger
target is used, the central point ixation target can be ring target is recommended, to provide an estimate of the
used, provided that the test pattern does not test the location of the ixation target.
central point. For this reason, the central point ixation

FIXATION TARGETS

CROSS MARK CENTRAL POINT RING

Standard Alternative For patients with severe
(do not use on test patterns visual field loss in the
with central locations) macula

10° 10°

FIGURE 3-10 Octopus perimeters offer 3 different fixation targets. The cross mark target is the default target. The central point
target can be used in test patterns that do not test the central point. The ring target is recommended for patients with fixation
issues due to severe visual field loss in the macula.
H ow to perf orm visual field testing 3 5

MONITORING THE PATIENT DURING THE EXAMINATION

To ensure good patient cooperation and trustworthy sponse even if there is no stimulus, or unsteady ixation),
results, it is essential to monitor patients throughout the the test should be interrupted and the patient should be
examination and not leave them unattended and unmon- reinstructed. If the results seem compromised, it is rec-
itored. During the test, it is helpful to encourage patients ommended to start a new test and discard the compro-
by telling them that they are doing well and by letting mised one. It is important to note, however, that patients
them know how much of the test they have already com- with impaired vision often do not respond due to their
pleted. This will help them to remain attentive and may re- condition and not because they answer unreliably.
duce anxieties that might negatively inluence the results.
If a patient shows inconsistent behavior, the examiner
Particular attention should be paid during the irst min- should make a note of this on the examination ile, to com-
ute of the test, to ensure that patients have understood municate this information to the clinician. The knowledge
what they are expected to do during the test. If a patient that the test has reduced reliability may inluence the
shows an unusual response (e.g., no response at all, a re- interpretation of the test.

USE OF FIXATION CONTROL

Loss of ixation is a primary reason for unreliable visual Control mechanisms active. However, since some patients
ield results. Therefore, all current Octopus devices have might not be able to maintain steady ixation for patholog-
a built-in Fixation Control for static testing that can track ical reasons (i.e., reduced central vision, unsteady pupil or
the patient’s pupil at all times and prevent ixation errors. nystagmus), individual mechanisms within Fixation Con-
With Fixation Control, the test is stopped automatically if trol can be turned off individually, to make patient testing
the patient loses ixation (due to blinking, searching for possible. If it is necessary to turn off some mechanisms,
stimuli or head movements) and automatically restarted careful patient monitoring is key and it is good practice to
once proper ixation is regained. Missed stimuli are au- make a note in the patient ile about the patient’s ability to
tomatically repeated later during the test. If ixation loss maintain ixation. The clinician should then interpret the
occurs for more than just a few seconds, a warning results in the light of this information and should consider
message will alert the examiner to properly reposition that the test might have reduced reliability.
and reinstruct the patient.
FIG 3-11 provides more information about the different
Fixation Control consists of several separate control control mechanisms of Octopus Fixation Control. Note
mechanisms, as outlined in FIG 3-11, which can be turned that the coniguration depends on the Octopus model.
on and off. It is recommended to keep each of the Fixation
36 Chapter 3 | How to perform perimetry you can trust

FIXATION CONTROL PREVENTS FIXATION LOSSES

BLINK CONTROL Prevents fixation loss due to blinking.

RUNNING PAUSED • Detects eye closure due to blinking or falling asleep

• Testing occurs only if the patient’s eye is open
• Allows the patient to blink normally
• Prevents dry eyes
• Increases patient comfort
• Ensures that no stimuli are missed due to blinking

CONTACT CONTROL Prevents loss of contact with the perimeter.

RUNNING PAUSED
• Detects contact with the headrest or chin rest
• Testing occurs only if the head is in contact with the device
• Ensures that the head remains close enough to the device to
minimize lens rim artifact

PUPIL POSITION CONTROL Prevents fixation losses due to incorrect pupil position.

RUNNING PAUSED • Detects off-centered pupils due to incorrect fixation or head

movement
• Testing occurs only if the pupil is correctly centered
• Ensures correct gaze direction

DART CONTROL Prevents fixation loss due to rapid eye movement.

RUNNING PAUSED • Detects rapid eye movement when the patient is searching
for stimuli
• Testing occurs only if the pupil is steadily fixating
• Ensures correct gaze direction

AUTOMATED EYE TRACKING (AET) Automatically adjusts the patient’s eye position.

RUNNING ADJUSTING POSITION • Moves the headrest and chin rest to keep the eye in the center
of the trial lens
• Maintains optimum position even if the patient is moving
around slightly
• Reduces trial lens rim artifacts due to off-centered eye
position

FIGURE 3-11 Fixation control prevents fixation losses by automatically pausing the test during blinks, loss of contact with
the device, off-centered pupils and rapid eye movements. The test is automatically restarted once optimum conditions are
achieved. Further, Automated Eye Tracking automatically centers the pupil. Note that not all mechanisms are available on the
different Octopus perimeter models.
Common pitfalls to avoid 37

COMMON PITFALLS TO AVOID

There are many factors that can lead to visual ield tests in the set-up procedure, and external obstructions block-
that cannot be trusted. By paying attention to and man- ing the stimuli from reaching the retina, are all commonly
aging these factors, a well-trained examiner will have a occurring sources of untrustworthy visual ield results.
substantial positive inluence on the quality of the visual Many of these pitfalls can be avoided by paying close at-
ield results and on the subsequent clinical decisions. tention to the set-up procedure, by observing the patient
Therefore, this section is dedicated to the most common carefully during testing, and by making adjustments or
pitfalls in perimetry and provides guidance on how to repeating instructions if necessary, which is the focus of
avoid them. this section. Chapters 7 and 8 provide information on
how to detect visual ield results that cannot be trusted
Patient behavior (i.e., lack of patient cooperation), errors after the test is completed.

INCONSISTENT PATIENT BEHAVIOR

LEARNING OR PRACTICE EFFECT

When taking their irst tests, patients often do not fully under- While learning and practice effects most often occur
stand the nature of the test and hesitate to press the button for patients taking their irst visual ield examination,
when seeing faint stimuli near the sensitivity threshold. This they can also occur when switching from one perimeter
translates into visual ield results that are worse than the pa- to another, due to small differences in the design (see
tient’s true visual ield, as illustrated in FIG 3-12. In subsequent Chapter 12).
testing, the patients then perform better and their visual ield
results resemble their true visual function more closely.

EXAMPLE OF A LEARNING EFFECT

LEARNING EFFECT NO LEARNING EFFECT

1st Test 2nd Test 3rd Test 4th Test 5th Test

FIGURE 3-12 Example of a patient with normal vision with a strong learning or practice effect from the first to third visual field
tests. The fourth and fifth tests represent the true visual field of the patient.
38 Chapter 3 | How to perform perimetry you can trust

While learning or practice effects cannot always be also helpful. If a patient does not understand the task of
prevented, their frequency can be reduced by careful pa- performing perimetry, the patient will often be hesitant
tient instruction and observation. Running a practice test during the irst part of the test, or will not press the re-
prior to real testing is a good procedure if time allows. sponse button at all. If this is observed, it is recommended
Careful observation during the irst minute of the test is to interrupt the test and reinstruct the patient.

FATIGUE EFFECT

Visual ield tests require alertness and attention. When vised to blink regularly to avoid dry eyes and discomfort,
patients become tired, their attention level may decrease given that Fixation Control is active. Artiicial tear drops
and their answers may become less consistent, resulting prior to the test may also reduce fatigue effects due to
in a visual ield that is worse than the patient’s true visual dry eyes. Additionally, patients should be encouraged to
ield (FIG 3-13).⁷-¹¹ take brief rests, by closing their eyes to relax, if they feel
that they are getting tired. Usually, this adds only a few
To reduce fatigue effects for patients who have dificulty seconds to the test duration, but signiicantly improves
concentrating for long periods of time, it may be appro- the reliability of the results. Furthermore, using a beep-
priate to use tests that are shorter in duration, despite ing sound upon each stimulus presentation may help the
the associated loss of accuracy. This may generate more patients to concentrate better on the test. BOX 3A pro-
meaningful visual ield results by reducing the unreliabil- vides more information about the advantages and disad-
ity due to the fatigue effect. Individual differences exist in vantages of this option.
how quickly patients experience fatigue, and this should
be considered when selecting a test. Sometimes fatigue is noticeable as drooping eyelids. In
such cases, it is best to actively interrupt the test for a while
To further reduce fatigue effects, patients should be ad- and to allow the patient to rest before continuing testing.

INFLUENCE OF FATIGUE EFFECT ON VISUAL FIELD

NO FATIGUE EFFECT FATIGUE EFFECT

9: 30 am 9:45 am

FIGURE 3-13 Example of a patient tested on the same day and eye within 15 minutes. Note the significant worsening of the
visual field in the second test, due to fatigue.
Common pitfalls to avoid 39

LOSS OF FIXATION

If a patient does not consistently ixate on the central tar- The Octopus Fixation Control should be enabled when-
get, the test will lose its reference point and it will not be ever possible, to avoid unreliable visual ields due to ixa-
possible to identify the location of abnormal visual ield tion losses. It should only be turned to a lower setting or
points (FIG 3-14). This is called ixation loss and is one of completely turned off if a patient is not able to maintain
the most common sources of unreliable ields.¹² It occurs steady ixation, for pathological reasons (i.e., reduced
especially if the patient is insecure about his or her per- central vision, unsteady pupil or nystagmus). Direct ob-
formance and starts looking around, searching for stimuli. servation of the patient’s ixation behavior early in the
To avoid ixation losses, it is therefore crucial to explain test can also be helpful in this regard.
carefully to the patient that it is perfectly normal not to
be able to see all of the stimuli.

INFLUENCE OF LOSS OF FIXATION ON VISUAL FIELD

CORRECT FIXATION LOSS OF FIXATION

Real defect is detected Real defect is missed and/or artifactual defect is identified

Do you see? Do you see?

Patient
Fixation Fixation
Target Loss of Fixation
Fixation
& Patient Target
Fixation

FIGURE 3-14 If there is a loss of fixation, visual field defects will not be in their exact location, but will either be shifted
together with the fixation or mask ed. In the above example, loss of fixation took place during the entire test. In practice, loss of
fixation is typically brief, resulting in more random defect patterns.

ADVANTAGES AND DISADVANTAGES OF USING SOUNDS UPON STIMULUS BOX 3A

PRESENTATION
A beeping sound upon stimulus presentation may be helpful for some patients, to maintain their atten-
tion during the perimetric test, because it provides them with a steady rhythm to follow. Additionally, it
provides reassurance to the patient that the test is running and everything is working normally.
However, the beeping sound may also encourage patients to press the response button even though
they cannot see a stimulus. This may increase false answers, resulting in unreliable visual ields. In
addition, if more than one perimeter is in a room, the beeping sound of neighboring machines may be
distracting.
By default, it is thus recommended to turn the beeping sound off and to only use it for selected patients
that have dificulties with maintaining concentration throughout the test.
40 Chapter 3 | How to perform perimetry you can trust

LACK OF PATIENT ATTENTION

Visual field tests require the patient’s full attention. Soothing and encouraging words from the visual ield
Distractions such as noise can negatively inluence the technician can strongly reduce these anxieties and in-
patient’s test performance. In addition, some patients crease the reliability of the results. Distractions should
experience anxiety when performing visual ield tests, also be reduced to a minimum. If the clinic layout does
due to fear that they are not performing well, or anxiety not offer a stand-alone perimetry room, light-dimming
about the outcome. curtains around the perimeter and ear muffs can offer a
cost-effective alternative.

TRIGGER-HAPPY PATIENTS

Some patients, consciously or unconsciously, want to answers carefully during the examination. If a patient
positively inluence the result of the visual ield test (e.g., responds to more than one false positive stimulus during
if their ability to drive is at stake, or if they fear a bad diag- the test, it will be helpful to interrupt the test immediately
nosis). These patients may be trigger-happy, pressing and reinstruct the patient, in order to avoid an unreliable
the response button even if they do not see a stimulus. result. Note that a beeping sound upon stimulus presen-
False positive trials where no stimuli are presented are tation may encourage trigger-happy patients to press the
used to detect trigger-happy patients (for more details, response button and it is thus recommended not to use
see Chapter 7). It is important to watch for false positive this, except in speciic situations.

MISTAKES IN THE SET-UP PROCEDURE

ACCURATE ENTRY OF PATIENT INFORMATION

Patient data, such as date of birth and refraction, need to measured sensitivities is compared to the data for an
be entered in the perimeter. It is important to ensure that average normal person of the same age, rather than an
this information is accurate. For example, if the wrong average normal person who is younger or older. FIG 3-15
date of birth is entered, most representations of the illustrates the inluence of incorrect patient age on the
visual ield test will be inaccurate, because each set of patient’s visual ield.

INADEQUATE CORRECTION OF REFRACTIVE ERROR

Inadequate correction of refractive error can lead to refraction for a patient. To avoid this, it is recommended
a blurring of the stimulus. If the patient does not have a to check the refraction on the same day as the perimetric
sharp image of the stimulus, the visual ield results will test. Even if the patient’s refraction has been checked
be worse than the patient’s true visual ield. Additionally, previously, it is possible that it may have changed since
a lens with too much plus power can lead to an artiicially then, especially among older patients.
enlarged visual ield, while a lens with too much minus
power will have the opposite effect. The second source of error is the incorrect choice of trial
lens. It is important to consult the user manual for the
The irst source of error is that the patient has been in- respective perimeter, as the choice of trial lens depends
correctly refracted, or that the examiner uses the wrong on the perimeter model. The paragraphs below describe
Common pitfalls to avoid 41

INFLUENCE OF INCORRECT PATIENT AGE ON VISUAL FIELD RESULTS

A CORRECT AGE B INCORRECT AGE C INCORRECT AGE

58 years Too old: 88 years Too young: 18 years

FIGURE 3-15 If the date of birth of a 58-year-old patient (A) is incorrectly entered, so that the patient’s age is 88 in the perim-
eter, the results will be artificially good (B). If the same patient is entered as an 18-year-old patient, the results will be artificially
bad (C).

the choice of trial lens for the current Octopus models To save time and avoid mistakes, it is recommended to al-
900 and 600. ways use the built-in trial lens calculator to determine the
required refractive lens. The trial lens calculator always
Patients need their far-distance correction for relaxed uses the patient’s actual best far-distance correction. It
vision. Depending on age, an added near-distance correc- then automatically calculates the necessary age-dependent
tion for presbyopia is also needed, because perimeters near-distance correction. It determines and recommends
test at near distances. It is important to use the adequate the trial lens with the lowest possible power, in order to
correction for presbyopia proposed by the perimeter’s minimize the risk of artifacts. BOX 3B presents the under-
manufacturer, and not the patient’s reading glass pre- lying assumptions of the trial lens calculator.
scription. Special attention should be given to noting the
sign (plus or minus) of the correction. If a minus lens is It is best practice to ask each patient prior to starting the
employed when a plus lens should have been used, the test whether they can see the ixation target sharply and,
patient’s vision may become blurry. if necessary, adjust the refraction so as to avoid inadequate
correction of the refractive error.

RATIONALE USED IN THE DESIGN OF THE TRIAL LENS CALCULATOR BOX 3B

DETERMINATION OF APPROPRIATE SPHERICAL LENS

The current Octopus perimeter models 600 and 900 present stimuli at a distance of 30 cm (11.8 inches)
from the eye. This corresponds to an approximate refraction of + 3.25 diopters (D), as calculated using
the following formula:

Power (D) = 1/stimulus distance (m) = 1/0.3 = 3.33

To enable the patient to focus at this distance, the patient’s far-distance refraction values are needed.
Depending on the patient’s refraction, different scenarios occur:
42 Chapter 3 | How to perform perimetry you can trust

N or mally sig h ted patients:

Young emmetropic patients can accommodate at 30cm, so they do not need an additional trial lens.
With increasing age, patients gradually lose their ability to accommodate their eyes (i.e., to change their
lens power) to objects presented at near distances. To facilitate near optical correction, additional diop-
ters (D) of refractive power are needed depending of the age of the patient (see table below).

H y per opic and pr esb y opic patients:

Hyperopic patient may have dificulty to focus at 30 cm. For these patients, a trial lens is needed, corre-
sponding to their refraction (R). As with emmetropic patients who are older, additional diopters (D) are
needed to support their near optical correction (presbyopia) (see table below).

M y opic patients:
Near sighted patients of up to -3 D do not necessarily need corrective lenses, as they can focus at 30
cm. Patients with strong myopia (greater than -3 D) will have dificulty focusing at 30 cm and need
additional correction. For refractive values above -3 D, add 3.25 D to the refractive value (e.g., for R =
-4 D; use a -0.75 D lens). As for presbyopic and emmetropic patients, with increasing age, near optical
correction is more dificult and additional diopters are needed.

C or r ections in th e cupola per imeter of O ctopus 9 0 0

Cupola perimeters allow for full-ield peripheral testing that extends beyond the range of a trial lens.
Therefore, all lenses and the lens holder must be removable to allow for peripheral testing. No trial lens
should be used for testing beyond 30° eccentricity. The Octopus 900 has a built-in trial lens calculator
to determine which trial lens should be used. The following look-up table shows the outputs of the
Octopus trial lens calculator.

Age Hyperopic Emmetropic Myopic

R>0D R=0D R = -0.5 D R = -1 D R = -1.5 D R = -2 D R = -2.5 D R = -3 D R < -3 D
< 30 R No lens No lens No lens No lens No lens No lens No lens R + 3.25
30 – 39 R + 1.0 D +1 +0.5 No lens No lens No lens No lens No lens R + 3.25
40 – 44 R + 1.5 D +1.5 +1.0 +0.5 No lens No lens No lens No lens R + 3.25
45 – 49 R + 2.0 D +2.0 +1.5 +1.0 +0.5 No lens No lens No lens R + 3.25
50 – 54 R + 2.5 D +2.5 +2.0 +1.5 +1.0 +0.5 No lens No lens R + 3.25
55 -59 R + 3.0 D +3.0 +2.5 +2.0 +1.5 +1.0 +0.5 No lens R + 3.25
>= 60 R + 3.25 D +3.25 +2.75 +2.25 +1.75 +1.25 +0.75 No lens R + 3.25

C or r ection in th e centr al field per imeter of th e O ctopus 6 0 0

In order to simplify the clinical worklow, the Octopus 600 perimeter has a built-in +3.25 D lens that
covers the central 30° of the visual ield. All patients, irrespective of age, therefore receive the maximum
correction for presbyopia. Only their actual refraction (R) is needed. If younger patients are over-cor-
rected, they are able to compensate by relaxing their lens without negative effect on their visual ield.

DETERMINATION OF APPROPRIATE CYLINDER LENS

C y linder C or r ection ( O ctopus 9 0 0 )

A cylinder correction can be discarded when the prescription is 0.25 D or less, because it does not alter
the result of the visual ield test. For cylinders from 0.5 to 1 D, the spherical equivalent is used and
added to the spherical lens needed for each patient. The spherical equivalent is calculated using the
following formula:

Spherical equivalent = ½ * cylinder correction

This formula is an approximation that adequately corrects for small cylinders, but does not suficiently
correct for cylinders larger than 1 D. For cylinders larger than 1 D, a cylindrical correction is needed.
Remember to get the cylinder axis oriented to the proper angle on the lens holder. (For the special case
of the Octopus 600 refer to the user manual).
Common pitfalls to avoid 43

EXTERNAL OBSTRUCTIONS BLOCKING STIMULI FROM

REACHING THE RETINA
LENS RIM ARTIFACTS

If the edge of the trial lens blocks the patient’s view (FIG so that the eye is as close as possible to the trial lens with-
3-16), the visual ield results will be adversely affected out touching it, and aligned in the center of the trial lens
and will show absolute defects at the edges. To avoid holder. The Octopus 900 provides a measurement func-
trial lens rim artifacts, the patient should be positioned tion to warn if the lens is too far from the eye.

INFLUENCE OF LENS RIM ARTIFACTS ON VISUAL FIELD RESULTS

A) B)

NO ARTIFACT LENS RIM ARTIFACT

FIGURE 3-16 If the patient is correctly positioned close to the trial lens (A), rim artifacts do not appear within 30° of the field
of view. If the patient is too far away from the trial lens (B), the edge of the visual field shows the rim of the lens.

FACIAL STRUCTURE OF THE PATIENT

It is important to observe the physiognomy (facial struc- Droopy lids (ptosis) and droopy lid skin (dermatochalasis)
ture) of the patient. A prominent nose, a heavy brow or long might also obstruct the patients’ upper ield of view (FIG
eyelashes can alter the ield of view, leading to misinter- 3-17). To avoid artifacts caused by ptosis, tape can be used
pretation of the visual ield results. If there is a prominent to lift the eyelid. Care should be taken to leave enough
facial structure, it is recommended to turn or tilt the freedom to allow blinking.
patient’s head to the side slightly, without losing ixation.

DIRTY CONTACT LENS

Since very high corrections can lead to peripheral dis- lenses are used, they must be inspected before the test.
tortions, it is advisable for a patient with very high cor- Dirty contact lenses reduce the amount of light entering
rections to wear contact lenses. Patients with moderate the eye, resulting in a diffuse defect. This will also appear
myopia may also leave their contact lenses in. If contact in the Defect Curve as a downward shift of the entire curve.
44 Chapter 3 | How to perform perimetry you can trust

PUPIL SIZE

The amount of light entering the eye is controlled by the observed. These artifacts may simulate glaucomatous
diameter of the pupil. As a rule, the pupil must have a visual ield defects. To avoid this, patients with a pupil
diameter of at least 3 mm for the results of the test to size of less than 3 mm, as measured in a dimly-lit room,
be trustworthy. Small pupils decrease the amount of may be dilated before the perimetric examination. Highly
incident light on the retina and result in a uniform de- artiicially dilated pupils may, however, occasionally lead
pression of the visual ield (FIG 3-18).¹³,¹⁴ Increasing to mild peripheral visual ield distortions.
diffraction around the margin of the pupil may also be

INFLUENCE OF FACIAL STRUCTURE ON VISUAL FIELD

A) PTOSIS

B) PTOSIS
WITH LID
TAPED UP

FIGURE 3-17 Ptosis (droopy lid) results in external superior obstruction of the visual field that is not related to any pathology
of the eye (A). Patients with severe ptosis or dermatochalasis should therefore be tested with the lid taped up (B), in order to
assess the visual field without the effect of ptosis, as seen in the example below.

INFLUENCE OF SMALL PUPIL SIZE ON VISUAL FIELD

SMALL PUPIL SIZE NORMAL PUPIL SIZE

Light Source

FIGURE 3-18 If a patient’ s pupil is too small, the overall sensitivity to light will be reduced, resulting in a visual field with diffuse
defect.
References 45

CLINICAL RELEVANCE OF UNTRUSTWORTHY VISUAL FIELDS

Obtaining reliable results is important in order to interpret The second most frequent cause of unreliable visual ields
the visual ields correctly. Unreliable visual ields unfor- was false positive errors, which accounted for 18% of all
tunately occur relatively frequently in clinical practice. In unreliable visual ields.² Of all the visual ield hemiields
more controlled conditions such as the large Ocular Hy- included in the OHTS, 0.4% had rim artifacts,¹² while
pertension Treatment Study (OHTS), ixation losses were superior and inferior depressions due to facial features
the most frequently observed cause of unreliable visual accounted for only 0.2% of all hemiields. In less controlled
ields, accounting for 70% of all unreliable visual ields.² conditions, these numbers may be signiicantly higher.

REFERENCES
1. Bickler-Bluth M, Trick GL, Kolker AE, Cooper DG. Assessing the utility of reliability indices for automated visual ields.
Testing ocular hypertensives. Ophthalmology. 1989;96:616-619.
2. Johnson CA, Keltner JL, Cello KE, et al. Baseline visual ield characteristics in the ocular hypertension treatment study.
Ophthalmology. 2002;109:432-437.
3. Johnson CA, Nelson-Quigg JM. A prospective three-year study of response properties of normal subjects and patients
during automated perimetry. Ophthalmology. 1993;100:269-274.
4. Katz J, Sommer A. Reliability indexes of automated perimetric tests. Arch Ophthalmol. 1988;106:1252-1254.
5. Katz J, Sommer A, Witt K. Reliability of visual ield results over repeated testing. Ophthalmology. 1991;98:70-75.
6. Fuhr PS, Hershner TA, Daum KM. Ganzfeld blankout occurs in bowl perimetry and is eliminated by translucent occlusion.
Arch Ophthalmol. 1990;108:983-988.
7. Gonzalez de la Rosa M, Pareja A. Inluence of the "fatigue effect" on the mean deviation measurement in perimetry.
Eur J Ophthalmol. 1997;7:29-34.
8. Hudson C, Wild JM, O'Neill EC. Fatigue effects during a single session of automated static threshold perimetry.
Invest Ophthalmol Vis Sci. 1994;35:268-280.
9. Johnson CA, Adams CW, Lewis RA. Fatigue effects in automated perimetry. Appl Opt. 1988;27:1030-1037.
10. Marra G, Flammer J. The learning and fatigue effect in automated perimetry. Graefes Arch Clin Exp Ophthalmol.
1991;229:501-504.
11. Wild JM, Searle AE, Dengler-Harles M, O'Neill EC. Long-term follow-up of baseline learning and fatigue effects in the
automated perimetry of glaucoma and ocular hypertensive patients. Acta Ophthalmol (Copenh). 1991;69:210-216.
12. Keltner JL, Johnson CA, Cello KE, et al. Classiication of visual ield abnormalities in the ocular hypertension treatment
study. Arch Ophthalmol. 2003;121:643-650.
13. Lindenmuth KA, Skuta GL, Rabbani R, Musch DC. Effects of pupillary constriction on automated perimetry in normal eyes.
Ophthalmology. 1989;96:1298-1301.
14. Wood JM, Wild JM, Bullimore MA, Gilmartin B. Factors affecting the normal perimetric proile derived by automated static
threshold LED perimetry. I. Pupil size. Ophthalmic Physiol Opt. 1988;8:26-31.
 47

CHAPTER 4
KEY EXAMINATION PARAMETERS

FIXED EXAMINATION PARAMETERS

Perimetric testing must be as standardized as possible, results. Chapter 12 provides an overview of the most
in order to allow comparisons over time and across common differences between devices and provides prac-
different eye care providing ofices. Therefore, many tical advice on how to successfully master the transition.
examination parameters are ixed by the perimeter
used and are not specifically selected by the user of For the sake of completeness, a summary of the most es-
the perimeter. These ixed parameters typically include sential ixed examination parameters of current Octopus
background color and luminance, maximum stimulus perimeters and the rationales behind them is provided
luminance and stimulus duration. in BOX 4A. Note that the settings presented below apply
to Standard Automated Perimetry. In special situations,
Different perimeter models use different ixed settings. other ixed examination parameters are chosen. They
Therefore, when switching from one device to another, are discussed in the respective chapters.
it is important to consider their inluence on the perimetric

FIXED EXAMINATION PARAMETERS BOX 4A

BACKGROUND INTENSITY AND COLOR

Background luminance (i.e., the relected light intensity of the background) determines the contrast
between the stimulus presented and the background, and thus has a considerable inluence on stimulus
perception. To achieve comparable test results, it must be kept constant.
The ideal background luminance of a perimeter should not be too bright, in order to allow display of
very dim stimuli for a large dynamic testing range. Neither should it be too dark, to avoid time-consum-
ing dark adaptation of the eye. It should stimulate selected cell types.
The standard background luminance of current Octopus models consists of white light with a lumi-
nance of 31.4 asb, which equals 10 cd/m. This luminance level is at the low end of photopic vision (i.e.,
the visual system used in normal daylight conditions) and does not require time for dark adaptation,
but still provides a high dynamic testing range. White light is used because it is detected by all cell types
in the retina and is therefore non-selective.

MAXIMUM STIMULUS LUMINANCE

As seen in Chapter 2, the maximum stimulus luminance (i.e., the maximum stimulus intensity) of a
perimeter deines the luminance associated with 0 dB on the decibel scale. It is also part of the formula
to calculate a decibel value from the stimulus luminance. If the maximum stimulus luminance were to
change, then the whole decibel scale would shift, so it must be kept constant for comparable results to
be achieved.
In order to offer a large dynamic testing range from normal to impaired vision, the maximum stimu-
lus intensity value should be as high as possible. However, when the maximum stimulus intensity is
48 Chapter 4 | Key examination parameters

too high, a part of it will be relected from the back of the eye (stray light) and will then be detected
by neighboring cells, which will produce inaccurate test results. Empirically, a maximum stimulus
luminance of 4,000 asb has been shown to offer a large dynamic range, while minimizing stray light
effects.,

STIMULUS DURATION
In order to reduce ixation losses, the perimetric stimulus duration (i.e., exposure time) is kept below
the reaction time of the human relex of quick eye movements towards rapidly appearing stimulus
(i.e., saccadic eye movement). As the reaction time of the saccadic eye movement is around 200 ms,
the stimulus duration should be shorter, but still suficiently long to be seen. For that reason, Octopus
perimeters use a standard stimulus duration of 100 ms.

PATIENT-SPECIFIC EXAMINATION
PARAMETERS
As described in Chapter 2, there is always a trade-off 1. Which type of perimetry should be used: static or
between testing time and accuracy in perimetric exam- kinetic perimetry?
inations. In this respect, it is very important to maximize 2. Which type of stimulus should be used: standard
the clinically relevant information, while at the same white-on-white, function-speciic or low-vision?
time minimizing test duration. As perimetry has a wide 3. Which test pattern should be used?
range of applications, there is no “one parameter its all” 4. Which test strategy should be used?
approach for all situations. Each Octopus perimeter thus
contains a library of standardized examination parame- The irst two questions are typically easy to answer.
ters from which the optimum set can be chosen for each Indeed, static and standard perimetry are indicated
patient. These patient-speciic examination parameters for the needs of patients in most clinical practices and
thus have to be selected for every patient. are by far the most commonly used types of perimetry.
With regard to test strategy and test pattern, various
In essence, there are four essential questions each clini- selections are commonly employed, and these decisions
cian must answer, in the order shown below, prior to must be made individually.
ordering a perimetric test:

TYPE OF PERIMETRY: STATIC OR KINETIC PERIMETRY

STATIC PERIMETRY

For reasons of simpliication, so far this book has concen- (FIG 4-1A). With this type of perimetry, it is possible to
trated on static perimetry. In static perimetry, stimuli of detect small changes in sensitivity thresholds with rel-
varying luminance levels are used to determine visual sen- atively high accuracy. For this reason, static perimetry
sitivity thresholds at a speciied number of ixed locations is the standard for slowly progressing diseases such as
P atient- spec ific ex am ination param eters 4 9

glaucoma. Since it is fully automated, it is also easy to use As the majority of visual ield tests are performed for
in clinical practice. glaucoma, static perimetry is the most commonly used
type of perimetry today.

KINETIC PERIMETRY

Kinetic perimetry was the irst quantitative method non-seeing to seeing areas. The patient response then
of performing visual ield testing and is an alternative deines the visual ield location of the speciic light sen-
to static perimetry. In kinetic perimetry, moving stim- sitivity threshold (FIG 4-1B).
uli of pre-determined light intensities are moved from

STATIC AND KINETIC PERIMETRY TESTING METHODS

A) STATIC PERIMETRY
Dim = Seen
Stimulus
= Not seen
Do you see No
the stimulus?
No
THRESHOLD
SENSITIVITY

No

Fixation
Yes

Yes

Yes

Stimulus Yes

Bright
Stimulus

B) KINETIC PERIMETRY

135
= Seen
Patient Do you see
response the stimulus? 150 = Not seen

165

180 Yes
Fixation
Yes
No
195
Yes

210
Vector
(Stimulus trajectory) No
225

FIGURE 4-1 Both static and kinetic perimetry are designed to provide visual sensitivity thresholds that allow mapping the hill
of vision of a patient. In static perimetry (A), stimuli of differing light intensity are shown at given locations, to determine the
sensitivity threshold at those positions. In kinetic perimetry (B), a stimulus of a given light intensity is moved along the visual
field (non-seeing to seeing), to determine the location of that sensitivity threshold.
50 Chapter 4 | Key examination parameters

After repeating this process for a speciic stimulus size for a given stimulus size and intensity and is similar to
and intensity across the entire visual ield, the visual sen- an altitude line on a geographical map. Local regions of
sitivity thresholds can be connected to form an isopter reduced sensitivity inside the isopter are identiied in the
(line of equal sensitivity). An isopter marks the boundary same way and are called scotomas. FIG 4-2 shows how
between seeing and non-seeing around the hill of vision static and kinetic perimetry results are displayed.

DISPLAY OF STATIC AND KINETIC VISUAL FIELDS

STATIC KINETIC

Isopter

Scotoma SEEING NON-SEEING

(here blind spot)

10 20 30 40 50 60 70 80 90

Scotoma
SEEING NON-SEEING (here blind spot)

FIGURE 4-2 In static perimetry, each sensitivity threshold is displayed independently, either as a color or as a numerical map
(not shown here). In k inetic perimetry, areas of eq ual sensitivity thresholds form an isopter that provides similar information to
static perimetry about the shape of defects. Local areas of depression inside an isopter are called scotomas.

Since the patient can report seeing the stimulus at any kinetic perimetry is currently not fully automated, making
location along the trajectory of the stimuli, kinetic perime- it more challenging in everyday use.
try provides high spatial resolution and fast testing over a
large area. It is therefore beneicial for diseases affecting As the majority of visual ield tests are performed to as-
the periphery and sharp-edged defects and is frequent- sess glaucoma and due to the ease of use of automation,
ly used to evaluate neurological diseases and peripheral static perimetry is by far the most commonly used type
retinal diseases. As moving stimuli are easier to see than of perimetry today. For that reason, all of the following
non-moving ones in the periphery, kinetic perimetry is paragraphs and chapters focus on static perimetry, while
also often used for children and for patients with cog- kinetic perimetry will be discussed in depth in Chapter 11.
nitive impairment or severe visual ield loss. However, The key differences between static and kinetic perimetry
are summarized in TABLE 4-1.
P atient- spec ific ex am ination param eters 5 1

COMPARISON BETWEEN STATIC AND KINETIC PERIMETRY TABLE 4-1

STATIC KINETIC

ADVANTAGES Clinical gold standard High spatial resolution

High precision sensitivity thresholds Fast peripheral testing

Fully automated Provides information about other visual functions

Highly interactive, lexible and adaptable

WHAT IT IS BEST Small changes in sensitivity thresholds Small changes in spatial extent of a defect
AT DETECTING
Changes in the central area Peripheral changes

Remaining vision in advanced diseases

COMMON USES Glaucoma Neuro-ophthalmological conditions

Macular diseases Peripheral retina diseases

Visual ability testing Low vision

Children

Patient with cognitive impairment

STIMULUS TYPE: STANDARD OR NON-CONVENTIONAL

STANDARD WHITE-ON-WHITE PERIMETRY

The standard perimetric stimulus is white on a white light allows visual ield testing from early to advanced
background, and this type of perimetry is commonly re- disease (i.e., it offers a large dynamic testing range). By
ferred to as white-on-white perimetry, or Standard Auto- convention, the standard stimulus used is round, with a
mated Perimetry (SAP). diameter of 0.43°, which is also the Goldmann stimulus
size III, based on the deinition of Professor Hans Gold-
The white color stimulus offers the advantage of stim- mann. For more information on Goldmann stimulus
ulating all different retinal cell types. As a result, white sizes, refer to BOX 4B.
52 Chapter 4 | Key examination parameters

BOX 4B GOLDMANN SIZES I TO V

The size conventions used today to describe a

perimetric stimulus are derived from the work BLIND SPOT V 1.7°
of Professor Hans Goldmann, who developed the
Goldmann perimeter in 1946. He deined standard
sizes for perimetric stimuli, and the Goldmann sizes 20 IV 0.8°
I to V are still widely used. Each step corresponds
to a change in diameter by a factor of 2 and in area
by a factor of 4. Size III is several times smaller than III 0.43°
the physiological blind spot and was considered to
be an accurate measurement size.
II 0.2°

The Goldmann stimulus siz es I to V are presented in I 0.1°

relation to the siz e of the physiological blind spot.

FUNCTION-SPECIFIC PERIMETRY

Function-speciic perimetry uses different stimulus types background (Short-Wavelength Automated Perimetry,
to stimulate different visual functions (e.g., motion, or or SWAP); a white lickering stimulus on a white back-
color vision), but they all have the same purpose: ground (Flicker Perimetry); or a pulsating stimulus with
measuring a subset of the visual system individually, to concentric rings changing in both spatial resolution and
get more sensitive responses for early disease detection. contrast (Pulsar Perimetry). They are described in more
Different Octopus perimeter models offer different func- detail in Chapter 10.
tion-speciic stimuli (FIG 4-3): a blue stimulus on a yellow

FUNCTION-SPECIFIC PERIMETRY

Time 1 Time 2

ON OFF

SW AP Flick er Pulsar

FIGURE 4-3 Stimuli used in function-specific perimetry from left to right: Short W avelength Automated Perimetry (SW AP), Flick -
er Perimetry and Pulsar Perimetry.
P atient- spec ific ex am ination param eters 5 3

PERIMETRY FOR LOW VISION

There is a limit to the visibility of the standard size III stimulus size V is typically used, instead of the standard
white perimetric stimulus in patients with signiicantly size III. It is 16 times larger in area and is therefore more
impaired visual sensitivity. In order to increase the dy- detectable. Chapter 10 provides more information about
namic range into the low vision region and to make the stimulus size V.
stimulus more visible to these patients, the Goldmann

OVERVIEW OF DIFFERENT STIMULUS TYPES TABLE 4-2

STANDARD FUNCTION-SPECIFIC LOW VISION

White-on-white, Pulsar, Flicker, SWAP White-on-white,

stimulus III stimulus V

ADVANTAGES Clinical standard Earlier detection in some Better visibility for patients
patients with signiicant visual ield
loss
Provides information about
other visual functions

WHAT IT IS BEST Follow-up of a disease Early loss in some patients Advanced visual ield loss
AT DETECTING from early to late stage

COMMON USES Glaucoma Conirm defects observed on Advanced glaucoma or

standard perimetry other ocular or neurological
diseases
Macular diseases Identify defects in glaucoma
suspects who do not
show defects on standard
perimetry
54 Chapter 4 | Key examination parameters

TEST PATTERN
In clinical practice, patients can sometimes become tired rough grid with 10° spacing between the stimuli would
quickly during perimetric testing, which signiicantly require approximately 190 test locations, but would be
limits the number of test locations that can be reliably highly inaccurate, as there would be only 5 test points in
tested.- A reasonably dense grid of test locations, cover- the central 10° of vision, which is an important area for
ing the entire visual ield with 2° spacing, would require visual functions such as reading and identifying objects
around 4,800 size III stimuli, and a grid with 6° spacing (FIG 4-4).
would require approximately 550 test locations. A very

ILLUSTRATION OF THE LOW SPATIAL RESOLUTION OF PERIMETRIC TESTING

10º SPACING 6º SPACING 2º SPACING

~190 siz e III targets ~550 siz e III targets ~4800 siz e III targets

90 90 90

180 0 180 0 180 0

270 270 270

FIGURE 4-4 Covering the entire visual field with high resolution within a reasonable test duration is not possible. Either the field
is only roughly covered, or the test duration is unacceptable, as shown in this example with three different test patterns.

In order to maximize perimetric information and mini- offer a large library of testing patterns for common
mize test duration, a test pattern should be chosen with perimetric applications.
a high density of test locations in the area of high inter-
est and a low density of test locations in areas of low The most commonly used test patterns available on the
interest (FIG 4-5). For that reason, Octopus perimeters Octopus perimeter and the rationale for which to select
are described in depth in Chapter 5.
P atient- spec ific ex am ination param eters 5 5

EXAMPLES OF DIFFERENT TEST PATTERNS

A) G-PATTERN B) M-PATTERN
(Glaucoma) (Macula)
90 90

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

270 270

C) ESTERMAN D) PTOSIS
(Visual driving ability)
90 90

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

270 270

FIGURE 4-5 Examples of test patterns for various clinical perimetric applications are presented. Each pattern maximizes the
relevant information for that clinical situation, while minimizing the test duration by only evaluating the most relevant areas. (A)
The G-pattern for glaucoma tests within 30° at locations that follow the retinal nerve fibre bundle patterns. (B) The M-pattern for
the macula tests within the central 10°. (C) The Esterman tests binocularly for visual fitness to drive (120° horizontally and 60°
vertically). (D) The Ptosis test pattern only evaluates the upper hemifield along common eyelid locations.
56 Chapter 4 | Key examination parameters

TEST STRATEGY
For the detection and follow-up of a disease, the sensi- stimulus luminance) to 32 dB (approximate foveal sensi-
tivity thresholds should be determined with high accu- tivity threshold of a 20-year-old on the Octopus 900), 32
racy. However, in clinical practice, even very cooperative stimuli would have to be presented at one test location.
and reliable patients experience fatigue, which limits the Performing the same procedure in 2 dB steps would re-
number of stimulus luminance levels that can be pre- quire 16 stimuli, while 4 dB steps would still require the
sented during a perimetric test. If we were to sample presentation of 8 stimuli (FIG 4-6).
the entire range in steps of 1 dB, from 0 dB (maximum

ILLUSTRATION OF THE LOW RESOLUTION OF SENSITIVITY THRESHOLDS IN PERIMETRIC TESTING

4 dB PRECISION 2 dB PRECISION 1 dB PRECISION

Up to 8 Up to 16 Up to 32
stimuli/location stimuli/location stimuli/location

32 dB 32 dB 32 dB

0 dB 0 dB 0 dB

FIGURE 4-6 Determining a sensitivity threshold with high precision with a sequence of stimuli of increasing intensity is not pos-
sible. Either too many stimuli are required, or the step sizes are too large, as the example with three different step sizes demon-
strates.

Instead of using the strategy of increasing stimulus inten- they only assess whether stimuli are seen or unseen (FIG
sity step by step until the sensitivity threshold is reached, 4-8). Qualitative strategies are commonly used in legal vi-
an eficient strategy is therefore needed that maximizes sual ability evaluations, such as in the tests used to assess
precision but minimizes test duration. visual itness to drive. Examples of a quantitative and a
qualitative test strategy are given in FIG 4-7 and FIG 4-8,
Octopus perimeters offer several test strategies with dif- for the sake of illustration.
ferent trade-offs between test duration and accuracy for
different clinical situations. Some strategies are quanti- The most commonly used strategies available on the
tative, which means that they are used to determine a Octopus perimeter and the rationale for which strategy
sensitivity threshold (FIG 4-7). Qualitative strategies are to select are described in depth in Chapter 6.
also offered in which the testing time is reduced, because
P atient- spec ific ex am ination param eters 5 7

EXAMPLE OF A QUANTITATIVE STRATEGY

= Seen
QUANTITATIVE STRATEGY
= Not seen

Do you see?

30 dB

2 Sensitivity
Threshold
3
Threshold Zone 5
4

0 dB
1. 2.
Sampling in Detailing within
large steps threshold zone

FIGURE 4-7 Example of a quantitative thresholding strategy: The visual field is first scanned with stimuli with large steps in light
intensity, in order to identify a suspected threshold zone. Once that zone has been identified, further testing inside that zone will
allow for determination of an accurate threshold with minimal test duration.

EXAMPLE OF A QUALITATIVE STRATEGY

= Seen
QUALITATIVE STRATEGY
= Not seen

Do you see? Do you see?

30 dB 30 dB

Sufficient Sufficient
vision to drive vision to drive

Patient Patient
is not fit is fit
Insufficient to drive Insufficient to drive
vision to drive vision to drive

0 dB 0 dB

FIGURE 4-8 Example of a qualitative strategy: For visual driving ability, one stimulus is shown at the fixed stimulus intensity
which is the minimum needed to drive safely. If a person sees that stimulus at a required number of test locations, this means
that the person fulfills the visual field criteria to be able to drive.
58 Chapter 4 | Key examination parameters

REFERENCES
1. Fankhauser F, Haeberlin H. Dynamic range and stray light. An estimate of the falsifying effects of stray light in perimetry.
Doc Ophthalmol. 1980;50:143-167.
2. Anderson RS, Redmond T, McDowell DR, Breslin KM, Zlatkova MB. The robustness of various forms of perimetry to
different levels of induced intraocular stray light. Invest Ophthalmol Vis Sci. 2009;50:4022-4028.
3. Johnson CA, Adams CW, Lewis RA. Fatigue effects in automated perimetry. Appl Opt. 1988;27:1030-1037.
4. Wild JM, Searle AE, Dengler-Harles M, O’Neill EC. Long-term follow-up of baseline learning and fatigue effects in the
automated perimetry of glaucoma and ocular hypertensive patients. Acta Ophthalmol (Copenh). 1991;69:210-216.
5. Hudson C, Wild JM, O’Neill EC. Fatigue effects during a single session of automated static threshold perimetry.
Invest Ophthalmol Vis Sci. 1994;35:268-280.
6. Gonzalez de la Rosa M, Pareja A. Inluence of the “fatigue effect” on the mean deviation measurement in perimetry.
Eur J Ophthalmol. 1997;7:29-34.
 59

CHAPTER 5
SELECTING A TEST PATTERN

INTRODUCTION
Depending on the pathology or type of ability testing different eye care providing ofices, test patterns are
that is to be performed, certain test locations are far standardized. However, various patterns have been
more relevant than others. As there is always a trade-off developed and different patterns can be used for the
between test duration and accuracy in any perimetric same purpose. Octopus perimeters offer all of the most
test, a test pattern should be chosen with locations in commonly used patterns, to allow for testing continuity.
the relevant area.
The following section focuses on the most commonly used
For this reason, all Octopus perimeters offer a library patterns and provides rationales for which to choose in
of a variety of test patterns for each application. In or- speciic situations. TABLE 5-1 provides a summary of the
der for test results to be comparable between different most commonly used Octopus test patterns.
sessions, between different patients and even between

COMMONLY USED TEST PATTERNS FOR VARIOUS INDICATIONS TABLE 5-1

INDICATION RECOMMENDATION COMMON ALTERNATIVES

GLAUCOMA/CENTRAL FIELD G (Glaucoma) 32, 30-2, 24-2

MACULA M (Macula) 10-2

FULL FIELD (NEURO, RETINA) 07 Kinetic

FOVEA F (Fovea)

BLIND SPOT B (Blind spot) Kinetic

LOW VISION M, G, 07 depending on pathology Kinetic

SCREENING FOR ABNORMAL Screening 28

VISION

DRIVING ET (Esterman) FG (Führerscheingutachten), Kinetic

BLEPHAROPTOSIS BT (Blepharoptosis) Kinetic

BLINDNESS BG (Blindengutachten)
60 Chapter 5 | Selecting a test pattern

TEST PATTERNS FOR GLAUCOMA

TYPICAL VISUAL FIELD DEFECTS IN GLAUCOMA
Glaucoma is a disease resulting in the degeneration of 30° test pattern, which has become the standard for visual
retinal nerve iber bundles in the eye. Since the largest ield testing in glaucoma today. Conversely, the periphery
proportion of retinal nerve ibers is located within the is rarely affected in isolation in glaucoma,⁶ so that
central 30°,¹-⁴ most early to moderate glaucoma visual peripheral testing is less common in cases of glaucoma
ield loss occurs within the central 30°. Typical defect for diagnostic reasons and, if used at all, is aimed to
patterns follow the distribution of the retinal nerve iber assess a patient’s quality of life.
bundles and there is a clear separation along the superi-
or and inferior hemiields at the horizontal meridian. The In very advanced glaucoma, the visual field usually
typical patterns of visual ield loss due to glaucoma are constricts to a macular visual ield⁷ and testing outside
partial arcuate, paracentral, nasal step, arcuate, temporal the macula does not provide any further diagnostic
wedge and altitudinal defects (FIG 5-1).⁵ information. Therefore, it is common to switch to a 10°
macular test pattern in advanced glaucoma, in order to
Since glaucomatous visual ield defects typically occur track residual vision in that area with higher resolution⁷,⁸
within the central visual ield, the best trade-off between for the same test duration.
test duration and accuracy is achieved by using a central
Test patterns for glaucoma 61

TYPICAL VISUAL FIELD DEFECTS IN GLAUCOMA

PARTIAL ARCUATE PARACENTRAL NASAL STEP

DIFFUSE ARCUATE TEMPORAL WEDGE

ALTITUDINAL CONSTRICTED
(Double arcuate)

FIGURE 5-1 The typical visual field defects in glaucoma are the partial arcuate, paracentral, nasal step, diffuse, arcuate,
temporal wedge, altitudinal and constricted in advanced glaucoma (ordered according to freq uency of occurrence). All
manifest themselves within the central 30° visual field, so that central 30° testing in glaucoma care is standard.
62 Chapter 5 | Selecting a test pattern

STANDARD TEST PATTERN IN GLAUCOMA CARE

The standard perimetric stimulus is white, and is pre- light allows visual ield testing from early to advanced
sented on a white background. This type of perimetry disease (i.e., it offers a large dynamic testing range). By
is commonly referred to as white-on-white perimetry, convention, the standard stimulus used is round, with a
or Standard Automated Perimetry (SAP). diameter of 0.43°, which is also the Goldmann stimulus,
size III, based on the deinition by Professor Hans Gold-
The white color stimulus offers the advantage of stim- mann. For more information on Goldmann stimulus
ulating all different retinal cell types. As a result, white sizes, refer to BOX 4B.

G PATTERN

The G pattern was designed to serve as a multi-purpose tection of visual loss associated with glaucoma, but also
test and offers an excellent trade-off between test dura- neuro-ophthalmological and macular diseases.
tion and accuracy.9-12 There are 59 different locations
within the central 30° of the visual ield and they are To maximize the detection of glaucomatous visual loss, the
distributed in a pattern that facilitates not only the de- test locations are distributed along the retinal nerve iber
bundles, where visual loss is most likely to occur (FIG 5-2).

THE G PATTERN FOR GLAUCOMA

FIGURE 5-2 The distribution of the test locations in the G pattern follows the retinal nerve fiber bundles.
Test patterns for glaucoma 63

The G pattern (FIG 5-3) offers a high density of points in ant area of visual function for reading and object iden-
the paracentral area (down to 2.8° spacing), to facilitate tiication and allows for additional detection of macular
detection of paracentral scotomas, which are common in diseases. Additionally, many recent reports indicate that
glaucoma, yet sometimes missed by other patterns.12-14 there are structural and functional deicits which occur
The test grid also accentuates the nasal step and overall in the macula of glaucoma patients. 15,16 To detect
has more test points nasally than temporally – partly due common neurological diseases such as hemianopias and
to the presence of the blind spot, but also to account for quadrantanopias, there are no points located on the
the higher frequency of nasal visual ield loss in glaucoma. vertical and horizontal meridians in the G pattern.
Time is saved by not testing in the immediate region of
With 5 central points in the fovea and a total of 17 test the blind spot, where unreliable results typically tend
locations in the macula, it focuses on the most import- to be observed.

PATHOLOGY-BASED G PATTERN

FOVEA MACULA

90 90

180 10 20 30 0 180 10 20 30 0

270 30° 270 30°

NASAL STEP BORDERS OF QUADRANTS

AND HEMIFIELD
90 90

180 10 20 30 0 180 10 20 30 0

270 30° 270 30°

FIGURE 5-3 The pathology-based G pattern uses test locations following retinal nerve fiber bundles. It has a high density of
test locations (highlighted in red) in the macula and fovea region, to detect foveal and paracentral defects and tests along the
horiz ontal and vertical meridians (i.e., midlines), and to detect nasal step and neurological defects. Valuable testing time is
saved with a lower density of test locations towards the periphery and temporal areas.
64 Chapter 5 | Selecting a test pattern

ALTERNATIVE TEST PATTERNS FOR THE CENTRAL 30°

32/30-2 AND 24-2 PATTERNS

The 32, 30-2 and 24-2 patterns (FIG 5-4) are similar to longer to complete than the G pattern without providing
the G pattern in that they cover the central visual ield considerably more meaningful clinical information.
and respect the vertical and horizontal meridians. In con-
trast however, they are not optimized for speciic pathol- The 24-2 pattern is based on the 30-2 pattern, but the
ogies. Instead, all test locations are equidistant from each most peripheral ring of test locations is removed, except
other and separated by 6°. for the two nasal points. With only 54 test points, the
test duration of the 24-2 pattern is as short as that of the
Historically, the 32 pattern17 was initially used in the G pattern, but the test pattern is not optimized for typical
irst series of Octopus perimeters in 1977, while the 30-2 pathologies.
pattern was among the irst central patterns used on the
Humphrey Field Analyzer. These patterns are nearly Since it is optimized for pathology and quicker, the
identical to each other. The sole difference is that the G pattern is recommended for new patients. However,
30-2 pattern has 2 extra test locations in the blind spot, the 32/30-2 and 24-2 patterns are recommended when
which are omitted in the 32 pattern. With their 74 or 76 a large set of existing data taken from one of these pat-
test locations respectively, the 32/30-2 patterns take terns is available for a patient, and the eye care provider
wishes to have continuity in the testing procedure.

CENTRAL 30° TEST PATTERNS

32 30-2 24-2
74 test locations 76 test locations 54 test locations

90 90 90

180 10 20 30 0 180 10 20 30 0 180 10 20 30 0

270 30° 270 30° 270 30°

FIGURE 5-4 The 30-2 pattern is similar to the 32 pattern, but has 2 additional test locations in the blind spot area. The 24-2
pattern is an abbreviated version of the 30-2 pattern, with most peripheral locations excluded, except for the nasal step region.
Test patterns for glaucoma 65

FURTHER TEST PATTERNS FOR GLAUCOMA

MACULA TESTING PATTERNS FOR ADVANCED GLAUCOMA

In advanced glaucoma, the visual ield is typically con- information, it is common to switch to testing patterns
stricted to the macular area. In these situations, testing that solely evaluate the area of the macula.⁷,⁸
the full 30° will not offer a good trade-off between test
duration and the clinical information received, because For further information on macula patterns, please see
more than 65% of the locations will be in known areas of the section on the macula testing patterns M or 10-2.
non-seeing (FIG 5-5). To further maximize useful clinical

MACULA PATTERN FOR ADVANCED GLAUCOMA

G M

30°

12°

30° 12°

FIGURE 5-5 In advanced glaucoma with a severely constricted visual field, the focus of visual field testing is on the remaining
vision in the macula. In these situations, a macula pattern like the M pattern provides more clinically relevant information than
a central pattern such as the G pattern.

KINETIC PERIMETRY FOR ADVANCED GLAUCOMA

Since static testing is challenging for patients with alternative to static testing in such cases. For more infor-
advanced glaucoma,18-20 kinetic perimetry is a good mation, please see Chapter 11 on kinetic perimetry.

PERIPHERAL TEST PATTERNS TO ASSESS QUALITY OF LIFE

Even though the periphery is rarely affected in isolation be an add-on to the standard G pattern. The G-Peripheral
in glaucoma,21-23 there may still be a need to assess the pattern places strong emphasis on the nasal step area, as
peripheral vision, in order to evaluate the patient’s over- this is the most relevant peripheral location in glauco-
all quality of life. ma.21,24

In these situations, the G-Peripheral pattern (FIG 5-6) is For an in-depth and eficient assessment of the periph-
a very time-effective peripheral screening pattern, with ery in low-vision patients, the use of kinetic perimetry
only 14 test locations in the periphery, and is intended to should be considered.
66 Chapter 5 | Selecting a test pattern

ABBREVIATED G PATTERN FOR SCREENING

In some instances, a screening visual ield test is a con- duration and accuracy. It is an abbreviated version of
venient procedure for every patient, to make sure that the G pattern with only 28 test locations (FIG 5-6). The
visual ield loss is not missed as part of a routine eye locations have been chosen on the basis of their ability
examination. to predict glaucoma and other commonly occurring eye
diseases, such as macula defects, quadrantanopias and
For screening of a presumed healthy population, the hemianopias.25,26 The Screening 28 pattern is recom-
Screening 28 pattern offers a good trade-off between test mended to be used with the screening-P95 strategy.

ADDITIONAL TESTING PATTERNS FOR GLAUCOMA

G-PERIPHERAL SCREENING 28
14 test locations 28 test locations
90 90

180 10 30 40 50 60 70 80 90 0 180 10 20 30 0

270 90° 270 30°

FIGURE 5-6 The G-Peripheral pattern is an add-on to the G pattern, to quickly screen the periphery and dominantly the
peripheral nasal step in glaucoma. The Screening 28 pattern is used for routine screening of dominantly healthy patients.
T esting patterns f or neurologic al visual field loss 6 7

TEST PATTERNS FOR

NEUROLOGICAL VISUAL FIELD LOSS
TYPICAL VISUAL FIELD DEFECTS
IN NEURO-OPHTHALMIC CONDITIONS
Neurological conditions lead to a large variety of typical vision) visual ield defects, with congruity (similarity in
visual ield defect patterns which are very speciic, de- location, size and magnitude of the deicit) between the
pending on the location at which the visual pathways are two eyes being most common further back in the visual
affected (FIG 5-7).27 Lesions of the optic disc and optic pathways at or near the occipital lobe. Large lesions re-
nerve lead to unilateral (i.e., only affecting one eye) visual sult in complete hemianopias, although quadrantanopias
ield defects. Common optic nerve and nerve head diseas- and wedge-like defects are also common. While large
es include disc edema, optic neuropathies, optic neuritis, lesions also affect the central visual ield, small lesions
compressive lesions such as those caused by idiopathic may not extend to the central 30°. It should also be noted
intracranial hypertension, and a number of congenital that a complete homonymous hemianopia only indicates
abnormalities, such as optic nerve head drusen. Typical that the deicit is post-chiasmal and that all visual path-
visual ield defect patterns appear in the central 30° and way ibers leading back to the occipital lobe have been
include foveal and macular defects, enlarged blind spots, damaged.
or patterns similar to those occurring in glaucoma.
However, deicits in the far peripheral visual ield beyond To cover all of the aforementioned visual ield defects, the
30° also frequently occur. full visual ield needs to be thoroughly tested, with a high
density of test locations in the macula, the blind spot and
Chiasmal lesions resulting from diseases such as pitu- the central ield. Therefore, thorough neurological visual
itary adenomas and related lesions typically result in ield tests are time-consuming. If the type of disease is
bitemporal (i.e., left and right eye defects are mirrored) identiied, then the focus of testing can be in the area af-
hemianopias, which progress from the superior to the in- fected by the disease, in order to reduce the test duration.
ferior hemiield, but always respect the vertical midline.
Damage can be more pronounced in one eye than the To maximize perimetric information and minimize test
other. Postchiasmal lesions typically lead to homony- duration, kinetic perimetry should also be considered.
mous (i.e., left and right eye defects are on same side of
68 Chapter 5 | Selecting a test pattern

TYPICAL VISUAL FIELD DEFECTS IN NEUROLOGICAL DISEASES

LEFT TEMPORAL FIELD NASAL FIELD RIGHT TEMPORAL FIELD

Visual field of the left eye (OS) Visual field of the right eye (OD)
60°

60° 30° 90°

Retina
Optic disc (blind spot) 1
2
Optic chiasm 3
Optic tract
Optic radiations 4
5
(temporal lobe) 6
Lateral geniculate
body
7
Optic radiations
(parietal lobe)

Occipital lobe
Visual cortex
8

Optic nerve damage Chiasmal deficit Postchiasmal deficit

1 Caecocentral scotoma 4 Heteronymous 5 Homonymous hemianopia

(bitemporal) hemianopia

2 Nerve fiber bundle defect 6 Superior homonymous

4 Heteronymous quadrantanopia
(bitemporal) quadrantanopia Temporal lobe lesion

3 Central scotoma
7 Inferior homonymous
quadrantanopia
Parietal lobe lesion

8 Homonymous hemianopia
Occipital lobe lesion

FIGURE 5-7 Typical visual field defects in diseases are unilateral if the optic nerve is damaged, heteronymous (the two eyes are
mirror images) around the chiasm and homonymous (the two eyes show non-mirror symmetry) beyond the chiasm. Both hemi-
anopias (vertical hemisphere defect) and quadrantanopias (quadrant defects) are typical neurological visual field defects.
T esting patterns f or neurologic al visual field loss 6 9

THOROUGH ASSESSMENT OF NEUROLOGICAL

VISUAL FIELD DEFECTS
Given the wide variety of defect patterns in neuro- These patterns are presented in (FIG 5-8) and can be in-
ophthalmic diseases, several test patterns are required to dependently combined as needed.
test all relevant locations.

N PATTERN its 21 test locations extending from 0 to 3°, it provides a

rapid assessment of the important foveal region and can
The N pattern is designed to test the full visual ield. It is also be useful for other indications in which the fovea is
useful to detect any kind of neurological disease. It ex- affected.
tends from 40° nasally to 67° temporally and 40° verti-
cally. With its 54 test locations in the central visual ield B PATTERN
and an additional 17 locations in the peripheral visual
ield, it offers an excellent trade-off between test duration The B pattern is designed to detect the boundaries of
and accuracy in the detection of central and early periph- the blind spot with adequate accuracy to check for blind
eral neurological defects. spot enlargements. It covers the area around the blind
spot from 9 to 19° horizontally, and 9.5° superiorly to 19°
F PATTERN inferiorly in 2.5° steps. To account for tilted discs, extra
points are added at the superior, temporal corner and the
The F pattern is designed to detect foveal defects, such as inferior nasal corner. With its 54 test locations, it takes a
nerve compressions, with high accuracy and should relatively long time to complete, while spatial resolution
be used when this kind of pathology is suspected. With is limited to 2.5°.

DIFFERENT PATTERNS FOR NEURO-OPHTHALMOLOGY

N F B
71 test locations 21 test locations 54 test locations

90 90 90

180 10 30 40 50 60 70 80 90 0 180 10 0 180 10 20 30 0

270 90° 270 10° 270 30°

FIGURE 5-8 There are three test patterns for neuro-ophthalmic disease which can be combined independently: the N pattern
for the full field, the F pattern for the fovea and the B pattern to test the blind spot.
70 Chapter 5 | Selecting a test pattern

07 PATTERN

The 07 pattern is an alternative to the N pattern. is further described in the section on test patterns for
With its 130 test locations it is more thorough than retinopathies.
the N pattern, but also takes considerably longer. It

KINETIC PERIMETRY

Since static testing is time consuming in the periphery neurological diseases. For more information, see Chap-
and provides only a limited spatial resolution, kinetic ter 11 on kinetic perimetry.
perimetry is a very good alternative to static testing in

TEST PATTERNS FOR RETINOPATHIES

TYPICAL VISUAL FIELD DEFECTS IN RETINOPATHIES
Retinal diseases lead to a variety of typical visual ield For many reasons, perimetry is typically not the main
defects (FIG 5-9). Diseases such as age-related macular diagnostic tool to detect and follow up retinopathies.
degeneration (AMD) or drug-induced maculopathies Firstly, retinal lesions are easily identiied by fundus
lead to macula ield defects and consequently require a examination or imaging. Secondly, perimetry requires
macula testing pattern for visual ield testing. the patient to maintain steady ixation, which is chal-
lenging for patients with advanced pathologies affecting
Other commonly occurring retinopathies often affect the the macula. Many of these patients will also have a
far peripheral visual ield. For these conditions, a test non-foveal preferred retinal locus for fixation. And
pattern covering the entire visual ield is essential. The thirdly, many retinopathies require peripheral testing
visual ield defect patterns observed in retinopathies and a high spatial resolution of the visual ield pattern,
are usually irregular. While diabetic retinopathy results making this a challenging test for patients to undergo.
in small patchy peripheral visual ield defects, retinal
detachments and retinoschises result in one rather large Nevertheless, perimetry is a key test to assess visual
cohesive defect, and retinitis pigmentosa shows a ring function in patients with retinopathies and therefore
defect in early to moderate disease stages. Due to the continues to play a role in the management of retinal
irregularity of these defect patterns, a testing pattern with diseases. Additionally, retinal diseases may occur in
a high spatial distribution of test locations is necessary, combination with other common pathologies such as
which by deinition is a more time-consuming test. To glaucoma, so a good understanding of retinal visual ield
maximize perimetric information and minimize test defects remains essential.
duration, kinetic perimetry should also be considered.
This may be the most eficient method of evaluating the
far periphery.
Testing patterns for retinopathies 71

TYPICAL VISUAL FIELD DEFECTS IN RETINAL DISEASES

AMD DRUG-INDUCED MACULOPATHY

10°
MACULA

DIABETIC RETINOPATHY RETINITIS PIGMENTOSA

90°
FULL FIELD

FIGURE 5-9 Typical visual field defects in retinal diseases either affect the macula (e.g., AMD, drug-induced maculopathies)
or are characterized by patchy, irregular loss affecting the full visual field (e.g., diabetic retinopathy, retinitis pigmentosa).

TEST PATTERNS FOR THE MACULA

M PATTERN

The M pattern is the recommended pattern for macula The M pattern is most commonly used for the testing of
visual ield evaluation.28 With its 45 equally spaced test drug-induced maculopathies, to follow up advanced-stage
locations, with 1° spacing in the fovea (central 4°), it of- glaucoma patients, and for visual function testing in
fers the highest density of test locations in the most es- patients with AMD or other macular dysfunction.
sential area for visual function.28 The remaining 36 of the
81 test locations in total are radially arranged outside the
fovea (FIG 5-10).
72 Chapter 5 | Selecting a test pattern

10-2 PATTERN

The 10-2 pattern is the alternative to the M pattern, but The 10-2 grid is identical to that used on the Humphrey
is not physiology-based (i.e., there is no emphasis on the Field Analyzer, thereby allowing for continuity when tran-
fovea). Instead, all 76 test locations are equidistant, being sitioning from the Humphrey to the Octopus perimeter.
separated from each other by 2° (FIG 5-10). Its test dura-
tion is comparable to the M pattern.

MACULA TEST PATTERNS

M 10-2
81 test locations 76 test locations

90 90

180 10 0 180 10 0

270 10° 270 10°

FIGURE 5-10 Both the M pattern and the 10-2 pattern are designed to exclusively test the macula. While the M pattern is
physiology-based, with a high density of test locations in the fovea, the test locations are equidistant in the 10-2 pattern.

TEST PATTERNS FOR THE FULL FIELD

07 PATTERN

The 07 pattern is the recommended static testing pattern It provides reasonably high spatial resolution to be able
to identify the patchy peripheral visual ield loss associ- to identify larger retinal lesions with a test duration that
ated with a variety of retinal diseases, such as diabetic is acceptable for most patients. Nevertheless, the test
retinopathy, retinoschisis, retinal detachment and retinitis duration using a quantitative strategy is long, so that a
pigmentosa. qualitative test strategy offers a good trade-off between
test duration and accuracy (more details on quanti-
It has 130 test locations, extending from 70° temporally to tative and qualitative tests are provided in Chapter 6).
55° nasally, arranged radially with 15° spacing 29 (FIG 5-11).
Testing patterns for retinopathies 73

FULL FIELD TEST PATTERNS FOR RETINOPATHIES

07 D
130 test locations 58 test locations
90 90

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

270 90° 270 90°

FIGURE 5-11 Both the 07 and the D patterns focus on the periphery to detect common retinopathies affecting the periphery.
The 07 pattern is recommended because it is more exhaustive, but with 130 test locations it is a long test.

D PATTERN FOR DIABETIC RETINOPATHY

The D pattern has been designed speciically for diabetic shorter test duration than the 07 pattern, but it may
retinopathy. With only 58 test locations, only extending miss smaller, localized patchy loss if used for diabetic
to 50° in the periphery, it has a lower resolution than retinopathy in the early stages.
the 07 pattern (FIG 5-11). This allows for a signiicantly

KINETIC PERIMETRY

Since static peripheral testing is time consuming and peripheral retinopathies. For more information, see
provides only limited spatial resolution, kinetic pe- Chapter 11 on kinetic perimetry.
rimetry is a very good alternative to static testing in
74 Chapter 5 | Selecting a test pattern

TEST PATTERNS FOR VISUAL

ABILITY TESTING
Visual ability testing is often performed in a legal con- requirements and deines test conditions in great detail,
text, for example to assess a person’s visual ability to other legislation sets broader requirements. It is there-
drive, eligibility for a pension or presence of visual fore essential to be familiar with the statutory require-
disability. Therefore, highly standardized visual ield ments in one’s own country and to choose a testing
tests are prescribed by local law and must be adhered to pattern that adheres to these regulations.
strictly. While certain legislation sets very specific

TEST PATTERNS FOR VISUAL ABILITY TO DRIVE

Safe driving requires a large horizontal ield of view, to By law, in many countries visual ability to drive tests are
be able to notice other cars coming from the side, and a mandatory to obtain and maintain a driver's license.
fairly intact central ield of view, to be able to notice obsta- While the precise requirements differ according to local
cles ahead. As driving is performed with both eyes open, legislation, often a visual ield test is required. While the
the binocular ield of view is relevant for safe driving. legislation in some countries is rather vague, in other
countries a speciic test is requested.

ESTERMAN TEST

The Esterman test was developed by Ben Esterman30 The Esterman test contains 120 test points. It horizon-
and has become an accepted standard visual ield test tally spans 160°, and vertically from 30° superior to 60°
for driving ability that is available in most modern inferior (FIG 5-12). It is typically a binocular test since
perimeters. While this test must be used in countries that driving is undertaken binocularly, but a monocular
require it by law, it is also commonly used in countries in version is also available.
which there are broader statutory requirements.
Testing patterns for visual ability testing 75

ESTERMAN TEST PATTERN

90

180 10 30 40 50 60 70 80 90 0

270 90°

FIGURE 5-12 Driving ability tests such as the binocular Esterman test typically extend into the visual field area that can be
seen through the front windscreen of a car.

As this test has to meet legal requirements, the test pa- that are missed are marked with illed squares. The
rameters are clearly outlined and similar for all perim- percentage of seen points relative to all points results
eters. Each point is tested using a stimulus intensity of in the Esterman score (FIG 5-13). The Esterman score
1,000 asb on a background intensity of 31.4 asb. Points needed to fulill driving requirements varies in different
that are seen are marked with a plus sign and points legislations.

ESTERMAN TEST

Demo, John, 1/1/1945 (71yrs)

ID 00001
Both eyes / 05/05/2015 / 16:.3:05
Symbols

Points seen: 108 / 120

Points missed: 12 / 120
Esterman score: 90

80°

Points seen: 108 / 120

Points missed: 12 / 120
Esterman score: 90

OCTOPUS®

FIGURE 5-13 Print-out of a binocular Esterman test with the Esterman score. The Esterman score defines the percentage of
points seen in relation to all points. In this example, 108 out of 120 points were seen, resulting in an Esterman score of 90%.
76 Chapter 5 | Selecting a test pattern

ADDITIONAL DRIVING ABILITY TESTS

Octopus perimeters also offer the German driving ability Some legislations also accept driving ability tests per-
test FG (Führerscheingutachten). Additional driving ability formed with kinetic perimetry. For more information on
test patterns can be created using the custom test function. kinetic perimetry, see Chapter 11.

TEST PATTERNS FOR BLEPHAROPTOSIS

Visual ield testing for blepharoptosis is performed in To objectively assess the potential beneits of blepha-
order to objectively quantify the inluence of ptosis on roplasty for visual function, the affected eye is typically
visual function. If it is signiicant, many insurance com- tested twice: once under normal conditions, and once
panies accept blepharoplasty as a medically required with the lid taped up to mimic visual function after sur-
surgery, instead of a cosmetic surgery, and will cover gery (FIG 5-15). The difference in the superior visual
the cost. The acceptance criteria are not standardized ield between the taped and non-taped eye is then used
and local legislation, as well as the respective insurance to determine the beneits of blepharoplasty.
company, should be consulted.

BT PATTERN FOR BLEPHAROPTOSIS

The BT pattern is designed speciically for blepharoptosis ield (FIG 5-14).31 As there is no vision underneath the lid
testing and covers the area of the lid lines in the superior line, qualitative testing (seen, not seen) is suficient.

BLEPHAROPTOSIS TEST PATTERN

90

180 10 30 40 50 60 70 80 90 0

270 90°

FIGURE 5-14 The BT pattern for blepharoptosis testing covers the area of the potential lid line.
Testing patterns for visual ability testing 77

VISUAL FIELD TESTING FOR BLEPHAROPTOSIS

Demo, John, 1/1/1945 (71yrs)

Right eye (OD) / 03/21/2014 / 11:36:24

Symbols

90°

Points seen: 21 / 87
Points missed: 66 / 87
Score [%]: 24

OCTOPUS®

Demo, John, 1/1/1945 (71yrs)

Right eye (OD) / 03/21/2014 / 16:53:12

Symbols

90°

Points seen: 64 / 87
Points missed: 23 / 87
Score [%]: 74

OCTOPUS®

FIGURE 5-15 Visual field testing for blepharoptosis is typically performed twice. Once under normal conditions and once with
the lid taped up to mimic post-surgery condition. The difference between the two visual field tests determines the potential
benefits of blepharoplasty for visual function.

KINETIC PERIMETRY

Since static peripheral testing is time-consuming, kinetic visual ield testing in blepharoptosis. For more informa-
perimetry is a more time-eficient method to perform tion, see Chapter 11 on kinetic perimetry.
78 Chapter 5 | Selecting a test pattern

TEST PATTERN FOR VISUAL IMPAIRMENT

In many countries, there is a pension system to support quality of life. Typically, test patterns for visual impair-
visually impaired people. In order to determine a per- ment exhaustively test the central visual function and
son’s eligibility for such a pension, an objective visual also extend into the periphery.
function test is required that is related to a patient’s

BG PATTERN

The German examination to assess legal blindness, BG on legal requirements in Germany, but can also be useful
(Blindengutachten) tests at 55 locations extending radi- in other countries in which the legislation is less speciic.
ally out to 55° (FIG 5-16). This test was designed based

BG PATTERN
90

180 10 30 40 50 60 70 80 90 0

270 90°

FIGURE 5-16 The BG test pattern for visual impairment has 55 test locations and scans the entire visual field up to 55°.
References 79

REFERENCES
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2. Curcio CA, Allen KA. Topography of ganglion cells in human retina. J Comp Neurol. 1990;300:5-25.
3. Stone J, Johnston E. The topography of primate retina: a study of the human, bushbaby, and new- and old-world monkeys. J Comp Neurol.
1981;196:205-223.
4. Rovamo J, Virsu V. An estimation and application of the human cortical magniication factor. Exp Brain Res. 1979;37:495-510.
5. Keltner JL, Johnson CA, Cello KE, et al. Classiication of visual ield abnormalities in the ocular hypertension treatment study. Arch Ophthalmol.
2003;121:643-650.
6. Harrington DO, Drake MV. The Visual Fields: Text and Atlas of Clinical Perimetry. St. Louis: CV Mosby; 1990.
7. Weber J, Schultze T, Ulrich H. The visual ield in advanced glaucoma. Int Ophthalmol. 1989;13:47-50.
8. Rao HL, Begum VU, Khadka D, Mandal AK, Senthil S, Garudadri CS. Comparing glaucoma progression on 24-2 and 10-2 visual ield examinations.
PLoS One. 2015;10: e0127233.
9. Sugimoto K, Schötzau A, Bergamin O, Zulauf M. Optimizing distribution and number of test locations in perimetry. Graefes Arch Clin Exp
Ophthalmol. 1998;236:103-108.
10. Messmer C, Flammer J. Octopus program G1X. Ophthalmologica. 1991;203:184-188.
11. Flammer AJ, Jenni A, Bebie H. Keller B. The Octopus glaucoma G1 program. Glaucoma. 1987;9:67-72.
12. Roberti G, Manni G, Riva I, et al. Detection of central visual ield defects in early glaucomatous eyes: Comparison of Humphrey and Octopus
perimetry. PLoS One. 2017;12:e0186793.
13. Hood DC, Nguyen M, Ehrlich AC, et al. A test of a model of glaucomatous damage of the macula with high-density perimetry: Implications for the
locations of visual ield test points. Transl Vis Sci Technol. 2014;3:5.
14. Ehrlich AC, Raza AS, Ritch R, Hood DC. Modifying the conventional visual ield test pattern to improve the detection of early glaucomatous defects
in the central 10°. Transl Vis Sci Technol. 2014;3:6.
15. Asaoka R. Mapping glaucoma patients' 30-2 and 10-2 visual ields reveals clusters of test points damaged in the 10-2 grid that are not sampled in
the sparse 30-2 grid. PLoS One. 2014;9:e98525.
16. Asaoka R, Russell RA, Malik R, Crabb DP, Garway-Heath DF. A novel distribution of visual ield test points to improve the correlation between
structure-function measurements. Invest Ophthalmol Vis Sci. 2012;53:8396-8404.
17. Gloor B, Gloor E. Detectability of glaucomatous visual ield defects with the Octopus automatic perimeter. A comparison between program G-1 and
programs 31 and 32 and their combinations. Klin Monbl Augenheilkd. 1986;188:33-38.
18. Nowomiejska K, Wrobel-Dudzinska D, Ksiazek K, et al. Semi-automated kinetic perimetry provides additional information to static automated
perimetry in the assessment of the remaining visual ield in end-stage glaucoma. Ophthalmic Physiol Opt. 2015;35:147-154.
19. Nevalainen J, Paetzold J, Krapp E, Vonthein R, Johnson CA, Schiefer U. The use of semi-automated kinetic perimetry (SKP) to monitor advanced
glaucomatous visual ield loss. Graefes Arch Clin Exp Ophthalmol. 2008;246:1331-1339.
20. Scheuerle AF, Schiefer U, Rohrschneider K. Functional diagnostic options for advanced and end stage glaucoma. Ophthalmologe. 2012;109:337-344.
21. Caprioli J, Spaeth GL. Static threshold examination of the peripheral nasal visual ield in glaucoma. Arch Ophthalmol. 1985;103:1150-1154.
22. Drance SM, Susanna R, Fairclough M. Early defects in the visual ield in glaucoma (author's transl). Klin Monbl Augenheilkd. 1978;173:519-523.
23. Schulzer M, Mikelberg FS, Drance SM. A study of the value of the central and peripheral isoptres in assessing visual ield progression in the
presence of paracentral scotoma measurements. Br J Ophthalmol. 1987;71:422-427.
24. Stewart WC, Shields MB. The peripheral visual field in glaucoma: reevaluation in the age of automated perimetry. Surv Ophthalmol. 1991;36:59-69.
25. Turpin A, Myers JS, McKendrick AM. Development of visual field screening procedures: a case study of the Octopus perimeter. Transl Vis Sci Technol.
2016; doi: 10.1167/tvst.5.3.3.
26. Takahashi N, Hirasawa K, Hoshina M, Kasahara M, Matsumura K, Shoji N. Diagnostic ability and repeatability of a new supra-threshold glaucoma
screening program in Standard Automated Perimetry. Transl Vis Sci Technol. 2017;doi: 10.1167/tvst.6.3.7.
27. Rowe F. Visual ields via the visual pathway. Second ed. Boca Raton, FL: CRC Press, Taylor & Francis Group; 2016.
28. Kaiser HJ, Flammer J, Bucher PJ, De Natale R, Stümpig D, Hendrickson P. High-resolution perimetry of the central visual ield. Ophthalmologica.
1994;208:10-14.
29. Graf M, Meienberg O. Octopus perimetry in neuro-ophthalmologic diseases. A contribution to the problem of optimal program choice based on
427 cases. Klin Monbl Augenheilkd. 1991;198:530-537.
30. Esterman B. Functional scoring of the binocular ield. Ophthalmology. 1982;89:1226-1234.
31. Jacobsen AG, Brost B, Vorum H, Hargitai J. Functional beneits and patient satisfaction with upper blepharoplasty - evaluated by objective and
subjective outcome measures. Acta Ophthalmol. 2017;doi:10.1111/aos.13385.
 81

CHAPTER 6
SELECTING A TEST STRATEGY

INTRODUCTION
As illustrated in Chapter 4, determining sensitivity accurate but shorter test may yield more useful visual
thresholds by assessing all levels of stimulus intensity ield results.
(e.g., stimulus luminance) is not practical because of the
time it would require. Several strategies have therefore Another important factor is the reason for which the
been developed to minimize test duration while maxi- test is being performed. For example, in order to detect
mizing clinically relevant information. Some strategies and follow pathologies such as glaucoma, it is important
are quantitative, providing a good estimate of the local to be able to detect small changes in sensitivity thresh-
sensitivity thresholds, while others are qualitative and olds with high accuracy. To achieve this, an accurate
can only determine whether a stimulus of a given inten- quantitative strategy is needed. On the other hand,
sity is seen or not. areas with no clinically meaningful information such as
the blind spot or the area under the lid in ptosis test-
The optimal strategy for a given test situation depends ing can be identiied equally well with a qualitative test
on a number of factors. The patient’s ability to reliably that simply determines whether stimuli are seen or not
complete the test is a crucial factor. A test that is designed seen. Qualitative test strategies are also often suficient
to be very accurate can lead to inaccurate perimetric re- in legal performance ability tests to assess, for example,
sults if the patient is only able to perform reliably during whether someone fulills the visual ield requirements
a portion of the test. In such situations, a potentially less to drive. TABLE 6-1 summarizes the differences between
qualitative and quantitative testing strategies.
82 Chapter 6 | Selecting a test strategy

CHARACTERISTICS OF QUANTITATIVE AND QUALITATIVE STRATEGIES TABLE 6-1

QUANTITATIVE STRATEGIES QUALITATIVE STRATEGIES

(THRESHOLDING) (SCREENING)

ADVANTAGES Quantiication of sensitivity Faster compared to most

thresholds and visual ield losses quantitative strategies
Higher accuracy

WHAT IT IS BEST AT DETECTING Small changes in sensitivity Normal versus abnormal vision
Compliance with legally required
Ocular and neurologic pathologies
visual ield criteria
(e.g., ability to drive)
Absolute defects

COMMON USES All pathologies Visual ability tests

(e.g., glaucoma, age-related macular (e.g., driving, legal blindness, ptosis)
degeneration)
Pathologies with predominantly
absolute defects
(e.g., blind spot enlargement, certain neuro-
ophthalmological and retinal pathologies)
Screening of eyes for abnormality

Finally, it is also important to consider patient comfort. All quantitative and qualitative test strategies available
Tests of short duration are easier to perform and may on the Octopus perimeters are described in more detail
motivate patients to come regularly for follow-up testing. in the following sections.

QUANTITATIVE STRATEGIES
Quantitative sensitivity threshold strategies are used to offer higher accuracy, but it also has longer test duration.
obtain sensitivity thresholds at various locations within
the visual ield. They are commonly used to detect and In the second type of quantitative sensitivity threshold
follow pathological visual ield defects. One exception is the strategy, predetermined estimates (e.g., educated guesses)
detection and follow-up of pathologies that result in sharp are made about the sensitivity thresholds at each location
absolute defects such as blind spot enlargements, which based on information obtained from other neighboring
can be equally well detected with a qualitative strategy. visual ield locations. Systematic sampling at each lo-
cation is not performed. This approach is used in the
Two types of quantitative sensitivity threshold strategies Tendency-Oriented Perimetry (TOP) strategy, a shorter
are available. In the irst type, there is a systematic sampling test with reduced accuracy in some situations.
of the entire range of light intensities in large steps, with
further detailing within the expected sensitivity threshold The characteristics of these strategies are summarized in
zone using smaller steps. This approach is designed to TABLE 6-2 and are further detailed in the next paragraphs.
Quantitative sensitivity threshold strategies 83

CHARACTERISTICS OF THE TOP, DYNAMIC, LOW VISION AND NORMAL STRATEGIES TABLE 6-2

TOP DYNAMIC LOW VISION NORMAL

TEST DURATION* 2 – 4 minutes 6 – 8 minutes 6 – 8 minutes 10 – 12 minutes

WHAT IT IS BEST Contiguous defects Contiguous defects Contiguous defects Contiguous defects
AT DETECTING (central 30°)
Isolated defects Isolated defects Isolated defects
Peripheral defects Peripheral defects Peripheral defects
Mild sensitivity Sensitivity Mild sensitivity
threshold changes thresholds with low threshold changes
sensitivity

BEST SUITED FOR Patients struggling Patients with mild Low vision patients Patients with
with fatigue changes in sensitivity excellent
thresholds cooperation,
Busy practices
attention and
Patients with good
minimal fatigue
cooperation and
attention

COMMON USES Glaucoma Glaucoma Low vision Clinical research

Macula Macula
Periphery
(Neuro, Retina)

METHODOLOGY Spatial relationship Sampling with Sampling with 4 dB Sampling with 4-2-1
among sensitivity increasing step size step size dB step size
thresholds of (2 – 10 dB)
Start at 0 dB
neighboring zones
sensitivity

ACCURACY IN dB n/a From ± 1 dB (normal ± 2 dB ± 1 dB

vision) to ±5 dB
(Low vision)

*Test duration estimates are provided for the 30° G pattern with 59 test locations.

NORMAL STRATEGY
The normal strategy was the irst quantitative testing projects or used to detect early and shallow defects in
strategy built into Octopus perimeters. It provides the younger patients who have the endurance necessary to
determination of sensitivity thresholds with an accura- perform reliably on longer tests.
cy of about 1 dB.¹,² This strategy takes approximately 10
to 12 minutes per eye for the G pattern.³ Due to its rel- The normal strategy uses a 4-2-1 dB sampling procedure
atively long test duration and the availability of quicker to determine sensitivity thresholds. In this sampling pro-
tests, this strategy is no longer recommended for stan- cedure, stimuli are irst presented in 4 dB steps to ind
dard testing. The long test duration can lead to fatigue, the threshold zone. Further detailing occurs in 2 dB steps
and many patients show signiicantly reduced reliability and the sensitivity threshold is determined as the
in spite of the higher accuracy of this strategy. It is still average between the last seen and not seen stimuli.
available, however, and can be useful in clinical research
84 Chapter 6 | Selecting a test strategy

NORMAL STRATEGY

Do you see?

32 dB
1
20 dB 6
28 dB = Seen
24 dB 2 Threshold
19 dB = Not seen
20 dB 3
Threshold Zone 18 dB 5
16 dB 4

12 dB

8 dB
16 dB
4 dB

0 dB
1. Sampling in 2. Detailing with 2 dB
4 dB steps step in threshold z one

FIGURE 6-1 An example of the procedure used in the normal strategy is presented. The 4-2-1 brack eting procedure of the
normal strategy proceeds by first presenting stimuli in 4 dB steps (stimuli 1 to 4) to find the threshold z one, then further details
in 2 dB steps (stimuli 5 and 6 ), and finally determines the sensitivity threshold as the average between the last seen and not
seen stimuli.

Because the widely used dynamic strategy is a variation normal strategy, outlined in BOX 6A, is helpful for grasp-
of the normal strategy, understanding the details of the ing the dynamic strategy.

BOX 6A THE DETAILS OF THE NORMAL STRATEGY

The normal strategy initially tests one anchor point location in each of the four quadrants to determine
sensitivity thresholds at one position in each quadrant. Using this information as an initial stimulus
for neighboring locations, it then uses a 4-2-1 dB sampling procedure. This sampling procedure is
also referred to as bracketing, and is performed using the staircase procedure in which two response
reversals (irst from “not seen” to “seen” and then from “seen” to “not seen”) are required. For example,
the test begins by presenting a stimulus at an intensity that corresponds to a given sensitivity threshold
(e.g., 28 dB). If this stimulus is not seen, the next stimuli are presented in decreasing 4 dB steps, until
the stimulus is seen (e.g., 16 dB; FIG 6-1). At this point, the procedure switches to a second crossing of
the threshold, but now in steps of 2 dB. The initial stimulus of that sequence is presented at 18 dB. If it
is "seen", the following stimuli are presented in increasing 2 dB steps until "not seen" (second response
reversal); however, if the 18 dB stimulus is "not seen", the following stimuli are presented in descend-
ing 2 dB steps until "seen". In both cases, the sensitivity threshold is calculated as the mean of the last
“seen” and “not seen” stimuli (FIG 6-1). It is expressed in dB with an uncertainty of approximately ±1 dB.
Except for the anchor points, the level of the initial stimulus is determined from the results already ob-
tained at neighboring test locations, in order to further reduce test duration. It is important to note that
even though information from neighboring test locations is used, each sensitivity threshold is deter-
mined independently of the neighboring sensitivity thresholds with the sampling procedure described
above. Typically, the procedure requires about 4 – 5 stimuli per test location.
It is possible for the patient’s sensitivity threshold to be above the level of the initial stimulus. This occurs
when the irst stimulus presented is seen. In this situation, the next stimulus is presented in increasing
4 dB steps until "not seen". The rules for the second crossing of the threshold remain the same.
Quantitative sensitivity threshold strategies 85

DYNAMIC STRATEGY
The dynamic strategy is a widely used procedure because In the dynamic strategy, the determination of the level of
it offers an excellent trade-off between test duration and the irst stimulus at a given test location follows the same
accuracy.⁴,⁵ It provides detailed information about each rules as the normal strategy (i.e., anchor points and in-
visual ield location and has been shown to detect early formation from neighboring locations). Test time is saved
visual ield loss and isolated visual ield defects reliably.⁶ mainly because the sensitivity threshold is crossed only
It is also a relatively quick test, taking an average of 6 to 8 once (i.e., only one reversal). Depending on whether the
minutes per eye when using the G pattern.⁷ Furthermore, irst stimulus is seen or not, the next stimulus is present-
this strategy can be used with all test patterns. ed in increasing or decreasing steps until the threshold
is crossed. The threshold is determined as the average
The dynamic strategy is based on the normal strategy, between the last seen and unseen stimuli. In areas of the
but it has been optimized to shorten test duration while visual ield that are near the normal range, an accuracy of
missing only a minimal amount of clinically relevant in- approximately ±1 dB is achieved to support early disease
formation.⁴,⁸ Similar to the normal strategy, it narrows in detection. In areas of advanced defects, an accuracy of
on the sensitivity threshold by using a modiied staircase approximately ±5 dB is achieved.
sampling procedure.
While the sensitivity thresholds may not be as accurate
In comparison to the normal strategy, the dynamic strat- as those obtained using the normal strategy in more ad-
egy step size is smaller in regions of normal sensitivity vanced disease, various clinical studies have shown that
and larger in areas where defects are present, ranging the dynamic strategy is adequate for low-vision patients.
from 2 dB to 10 dB (FIG 6-2). This saves considerable This is because more accurate testing is not possible due
time when signiicant visual ield loss is present. The to an increase in luctuation.⁴,⁸,¹⁰
variable step size is justified, as fluctuation has been
shown to increase with increasing defect depth.⁹ Testing
can therefore be performed using a step size tailored to
the degree of luctuation.⁴
86 Chapter 6 | Selecting a test strategy

DYNAMIC STRATEGY

Do you see?

32 dB
= Seen
28 dB
1 = Not seen
24 dB
2
20 dB
3
16 dB Threshold
Threshold Zone
14.5 dB
12 dB
4
8 dB

4 dB

0 dB
Sampling with
increasing
step siz e

FIGURE 6-2 An example of the procedure used in the dynamic strategy is presented. The dynamic strategy samples with
increasing step siz e (from 2 to 10 dB from normal sensitivity threshold) after the first stimulus is not seen until a stimulus is
seen without any further detailing. As a result, the accuracy is between ± 1 and ± 5 dB, depending on the step siz e.

LOW-VISION STRATEGY
The low-vision (LV) strategy is useful for assessing pa- longer because more stimuli would be presented in lo-
tients with end-stage diseases, when only limited visual cations where there is no sensitivity.
ield function remains. It employs a methodology similar
to the normal strategy, but only performs one threshold Besides saving test time, the low-vision strategy is also
crossing (4-2 bracketing), which reduces test duration. more patient-friendly for low-vision patients, because
While an accuracy of only approximately ±2 dB can be starting the test with the maximum stimulus intensity
achieved, this is justiied by the large luctuation in increases the likelihood that the initial stimulus will be
areas of low vision.⁹ In addition, the low-vision strat- seen. This allows patients to feel conident about their
egy starts testing at a sensitivity threshold of 0 dB (FIG performance in the initial stage of the test.
6-3). This means that the initial stimulus used is at the
maximum stimulus intensity because of the inverse re- In order to extend the dynamic testing range into the
lationship between light intensity and sensitivity thresh- low-vision area and also to make the target easier to see
old, as outlined in FIG 2-2. This approach further reduces for low-vision patients, the low-vision strategy is typically
test duration when a visual ield contains a large number used in combination with a stimulus size V that is pre-
of locations with absolute defects. For such situations, sented for 200 ms (see Chapter 10 for more information
testing with the dynamic or normal strategy would take on stimulus size V for low-vision patients).
Quantitative sensitivity threshold strategies 87

LOW-VISION STRATEGY

Do you see?

32 dB
= Seen
28 dB
= Not seen
24 dB

20 dB

16 dB

12 dB

8 dB 3
Threshold
Threshold Zone 6 dB
4 dB 2

0 dB 1
Sampling in
4 dB steps

FIGURE 6-3 The low-vision strategy is optimiz ed for low-vision patients and is a variation of the normal strategy. Significant
test time is saved by crossing the threshold only once. Patient confidence is also increased by starting at a sensitivity threshold
of 0 dB, the maximum stimulus intensity available on the device.

TENDENCY-ORIENTED PERIMETRY (TOP) STRATEGY

The Tendency-Oriented Perimetry (TOP) strategy is related to the sensitivity thresholds at nearby locations
a widely used and fast procedure. It takes only two to (i.e., there is a spatial correlation among adjacent test lo-
four minutes per eye for a complete sensitivity thresh- cations). During the test, answers at any given location
old examination with the G pattern.³,¹¹-¹³ Because of its are taken into account to adjust the expected sensitivity
short duration, it is especially recommended for patients thresholds at neighboring locations. The test starts by
unable to maintain concentration for long periods, such presenting stimuli at 50% of normal sensitivity thresh-
as the neurologically impaired or children.¹⁴ For these olds at a quarter of the test locations. If the stimulus at
patients, fatigue or lack of concentration in a longer test a certain location is missed, the stimuli at immediately
would lead to unreliable results.¹⁵,¹⁶ The TOP strategy is adjacent locations are presented at lower sensitivity
also useful as a practical routine method for testing and thresholds. However, if the stimulus is seen, the initial
following patients of all age groups, especially in busy stimuli at neighboring locations are presented at higher
practices.¹⁶ sensitivity thresholds. This procedure is repeated for all
test locations with answers from neighboring test loca-
The TOP strategy takes advantage of the fact that sensi- tions leading to an adaptation of all test locations. See
tivity thresholds at each location of the visual ield are BOX 6B for more details.
88 Chapter 6 | Selecting a test strategy

BOX 6B TOP STRATEGY – STEP-BY-STEP PROCEDURE

STEP 0 Normal
• Baseline: normal Sensitivity Threshold
sensitivities at each
test location 27 28 28 28
29 30 31 31 31 28 29 29 29 29 28
• Test pattern divided into
29 30 31 31 31 31 30 30
4 sub-test patterns 30 31 31 32 32 29 30 31 31 32 32 32 31 30 30
29 30 32 32 33 33 32 BS 31 30
30 32 32 33 33 30 30 32 32 33 33 32 BS 31 30
30 30 31 32 32 32 32 31 30 30
30 32 32 33 33 28 30 31 31 31 31 30 30
28 29 30 30 30 29
30 31 32 32 32 29 29 29 29

STEP 1A STEP 1B
• Submatrix 1 = ½ of Submatrix 1 Response Matrix 1 • Seen: Add ¼ of
normal sensitivity normal sensitivity
• Stimulus presentation 15 15 16 16 16 7 8 8 0 -8 • Not seen: Substract ¼
on 1st sub-test pattern of normal sensitivity
15 16 16 16 16 8 8 8 0 -8
STEP 1C
15 16 16 17 17 8 8 8 0 -8 Calculate responses for
sub-test patterns 2 – 4
15 16 16 17 17 8 8 8 4 0 from average of
neighboring locations
15 16 16 16 16 8 8 8 8 8 by interpolation

STEP 2A STEP 2B
• Submatrix 2 = Submatrix 1 Submatrix 2 Response Matrix 2 • Seen: Add 3/16 of
+ Response Matrix 1 normal sensitivity
• Stimulus presentation on 22 23 24 16 8 5 5 3 0 -3 • Not seen: Substract 3/16
2nd sub-test pattern of normal sensitivity
23 24 24 16 8 5 6 6 6 0
STEP 2C
23 24 24 17 9 6 6 6 6 0 Calculate responses for
sub-test patterns 1, 3, 4
23 24 24 21 17 6 6 6 6 0 from average of
neighboring locations
23 24 24 24 24 6 6 6 6 3
by interpolation

STEP 3A STEP 3B
• Submatrix 3 = Submatrix 2 Submatrix 3 Response Matrix 3 • Seen: Add 2/16 of
+ Response Matrix 2 normal sensitivity
• Stimulus presentation on 27 28 27 16 5 2 0 0 -2 -4 • Not seen: Substract 2/16
3rd sub-test pattern of normal sensitivity
28 30 30 22 8 4 4 4 0 -4
STEP 3C
29 30 30 23 9 4 4 4 2 0 Calculate responses for
sub-test patterns 1, 2, 4
29 30 30 27 17 4 4 4 4 4 from average of
neighboring locations
29 30 30 30 27 4 4 4 4 4
by interpolation
Quantitative sensitivity threshold strategies 89

STEP 4A STEP 4B
• Submatrix 4 = Submatrix 3 Submatrix 4 Response Matrix 4 • Seen: Add 1/16 of
+ Response Matrix 3 normal sensitivity
• Stimulus presentation on 29 28 27 14 1 -2 -2 -2 -2 -2
• Not seen: Substract 1/16
4th sub-test pattern of normal sensitivity
32 34 34 22 4 -2 -2 -1 0 0
STEP 4C
33 34 34 25 9 -2 -2 0 2 2 Calculate responses for
sub-test patterns 1 – 3
33 34 34 31 21 -2 -2 0 2 2 from average of
neighboring locations
33 34 34 34 31 -2 -2 0 2 2
by interpolation

STEP 5
• Sensitivity threshold = Sensitivity Threshold
Submatrix 4 + Response
14 3 0 0
Matrix 4 27 26 25 12 0 22 16 3 0 0 0
26 25 23 11 0 0 0 2
30 32 33 22 4 28 29 30 31 21 4 0 0 4 7
29 30 31 34 26 10 4 BS 5 7
31 32 34 27 11 29 30 31 34 33 22 16 BS 13 13
29 30 30 33 35 32 29 26 24 21
31 32 34 33 23 29 29 31 32 32 32 3 30
28 28 29 29 29 28
31 32 34 36 33 27 28 28 28

Because the initial stimuli are presented at a lower sensi- increased accuracy,¹⁵ this strategy also has some short-
tivity threshold – and thus higher light intensity (see FIG comings related to accuracy. The TOP strategy can reliably
2-2 for the inverse relationship between light intensity detect large contiguous scotomas such as those present
and sensitivity threshold) – in the TOP strategy than in in glaucoma.¹³,¹⁶,¹⁷ However, it smoothes the edges of
the dynamic or normal strategies, the likelihood of see- the scotomas¹⁸ (FIG 6-4) and is less sensitive to small,
ing most of the initial stimuli is increased. This allows localized defects compared to a systematic sampling pro-
patients to feel conident about their performance for cedure such as the dynamic strategy.⁶,¹¹,¹² These factors
the initial stage of the test, resulting in a shorter patient should be kept in mind when making clinical decisions.
learning curve, increased reliability for the initial exam-
inations, and possibly greater motivation for patients to In addition, the TOP strategy requires a reasonably dense
return for follow up testing. test grid to justify the assumption that there is a spatial
correlation between the test points. Therefore, it is only
While the advantages of the TOP strategy, in terms of available for the central 30° patterns G, 32, 30-2 and 24-2
reduction of test duration and fatigue effects, can lead to and the macula test patterns M and 10-2.
90 Chapter 6 | Selecting a test strategy

SPATIAL RESOLUTION OF NORMAL, DYNAMIC AND TOP STRATEGY

NORMAL DYNAMIC TOP

12 10 – 12 minutes 12 6 – 8 minutes 12 2 – 4 minutes
9 3 9 3 9 3
6 6 6

FIGURE 6-4 W hen choosing a test strategy, there is a trade-off between test duration and accuracy as the example above illus-
trates. The same patient was tested with the G pattern and the normal (left), dynamic (center) and TOP (right) strategies. Note
that while all strategies allow the identification of a double arcuate defect, the visual field measured with the TOP strategy shows
the defect as shallower with smoother edges, but it also saves considerable test time.

QUALITATIVE STRATEGIES
Qualitative strategies are useful and time-eficient when assessing the vision of patients with certain retinal pa-
the quantiication of a patient’s sensitivity threshold is thologies. Finally, they can be used to quickly screen
not necessary. These strategies are used for visual ield patients with assumed normal vision.
performance ability testing including driving,¹⁹ legal
blindness and ptosis examinations. They are also some- The answers obtained with these strategies are always
times used for pathologies that result in absolute defects. qualitative (e.g., seen/not seen or normal visual ield/
For example, qualitative strategies can be used to assess abnormal visual ield). Octopus perimeters offer several
the vision of patients with neurological conditions that qualitative strategies for different purposes, as described
result in hemianopia, quadrantanopia²⁰ and blind spot below.
enlargements. Furthermore, they can also be useful in
Qualitative strategies 91

1-LEVEL TEST STRATEGY (TWO-ZONE STRATEGY)

The 1-Level Test (1LT) is a fast test strategy most com- used to assess absolute visual ield defects such as blind
monly used for legal performance ability tests to assess spot enlargements or the lid margin in blepharoptosis
whether someone fulills the minimal visual ield criteria testing (FIG 6-5).
to drive or to perform other daily tasks. In addition, it is

EXAMPLES OF THE USE OF THE 1-LEVEL TEST STRATEGY IN DIFFERENT SITUATIONS

BLEPHAROPTOSIS BLIND SPOT BINOCULAR ESTERMAN

90 90 90

180 10 30 40 50 60 70 80 90 0 180 0 180 10 30 40 50 60 70 80 90 0

90° 30° 90°

270 270 270

FIGURE 6-5 Three examples of visual field tests performed with a 1LT strategy. For absolute defects such as the lid margin
in blepharoptosis testing (left) or blind spot testing (center), the 1LT strategy provides sufficient information to delineate the
boundaries. In the Esterman test (right), it is used to determine the percentage of test locations missed and provides informa-
tion about a patient’ s ability to drive.

With the 1LT strategy, only one stimulus is presented at displays stimuli at a ixed stimulus luminance of 1000
each test location at the predetermined intensity level asb (this is equal to10 dB at a maximum stimulus lumi-
of 6 dB below the normal sensitivity threshold. The pa- nance of 10000 asb) to comply with the legal require-
tient either sees or misses these stimuli (FIG 6-6). The ments of the test.
visual ield is consequently divided into two zones, seen
(represented by a “+” sign) and not seen (represented Be aware that typically more than one abnormal visual
by a “█”symbol). As a result, this strategy is sometimes ield location showing a disease-speciic pattern is re-
referred to as a two-zone strategy. Clinically, visual ield quired to classify a visual ield as abnormal. For more
locations with the “+” sign can be interpreted as normal detailed information on the distinction between normal
and those with the “█”symbol as abnormal. Note that and abnormal visual ields, see FIG 7-9, 7-10, 8-14 and
when used with the Esterman pattern, the 1LT strategy 8-15..
92 Chapter 6 | Selecting a test strategy

1-LEVEL TEST STRATEGY

Do you see? Normal Abnormal

visual field location visual field location

Normal

Stimulus
presented at
Abnormal 6 dB below
normal
sensitivity
threshold
= Seen

= Not seen

0 dB 0 dB

FIGURE 6-6 W ith the 1LT strategy, the visual field is divided into areas of lik ely normal and abnormal visual field locations.

SCREENING-P95 STRATEGY
The screening-P95 strategy is used to quickly distinguish with a routine eye examination. In that context, the screen-
between people with normal and abnormal visual ields. ing-P95 strategy together with the Screening 28 pattern
It is a very fast strategy and patients with normal visual offers a very good trade-off between testing time and accu-
ields can typically complete it within one minute. It is racy by being fast while at the same time allowing the identi-
designed to be used with the Screening 28 pattern. ication of patients with abnormal visual ields.21 If a visual
ield abnormality is detected during routine screening,
The screening-P95 strategy is useful and time-effective further quantitative testing is recommended to assess the
when routine visual ield testing is performed on every pa- extent and depth of visual ield loss (FIG 6-7).
tient to identify pathologies that would otherwise be missed
Qualitative strategies 93

EXAMPLE OF THE USE OF THE SCREENING-P95 STRATEGY

SCREENING TEST QUANTITATIVE TEST

Screening-P95 strategy Dynamic strategy
12 Screening 28 pattern 12 G pattern
9 3 9 3
6 6

+ +

+
+ +
+
+ +

+ + +
+
+
+ + +
+ + + +

+ + +
+

FIGURE 6-7 The routine testing with the screening-P95 strategy and the short Screening 28 pattern allows the identification
of potentially unnoticed visual field defects with minimal test duration. This can identify patients who req uire a more detailed
evaluation. In the case presented above, a patient with early glaucoma was detected during routine screening, and conseq uent
q uantitative visual field testing confirmed the existence of the previously unnoticed partial arcuate defect.

The screening-P95 strategy is a modiied version of the rienced with visual ield testing. If the patient sees the
1-Level Test strategy (FIG 6-8). The irst stimulus at each stimulus on any of these repetitions, the location is des-
location is presented at the intensity that an average sub- ignated as normal (represented by a “+” sign), otherwise
ject with a normal visual ield would see 95% of the time. it is recorded as abnormal (represented by a “█” sign).
If the point is seen, the location is designated as normal. Because unseen points are tested three times, the likeli-
If it is not seen however, the same point is repeated twice hood of obtaining false negative errors is reduced. This
to conirm suspected abnormalities and to avoid false approach results in better speciicity for the screening
negative errors, which are common in patients inexpe- test.22

EXAMPLE OF THE USE OF THE SCREENING-P95 STRATEGY

Do you see? Normal Normal Abnormal

visual field location visual field location visual field location

Normal

Stimulus
intensity
Abnormal that people
with normal
visual fields
see 95%
of time
= Seen

= Not seen

0 dB 0 dB 0 dB

FIGURE 6-8 The screening screening-P95 distinguishes between normal and abnormal visual fields by presenting a stimulus at
an intensity that people with normal visual fields would see 95% of the time.
94 Chapter 6 | Selecting a test strategy

2-LEVEL TEST STRATEGY (THREE-ZONE STRATEGY)

The 2-Level Test (2LT) strategy is similar to the 1LT, but fatigue. In such situations, the 2LT strategy offers a good
presents stimuli at two sensitivity thresholds. It conse- trade-off between test duration and accuracy, often with
quently divides the visual ield into three zones and is only minimum loss of clinical information (FIG 6-9).
thus also referred to as a three-zone strategy.
The 2LT strategy provides only a rough indication of the
The 2LT strategy is commonly used as an alternative to status of the visual ield. It is designed to distinguish
the quantitative dynamic strategy to assess the full visual between areas of normal visual ield, areas with relative
ield in pathologies that result in hemianopia, quadran- defects (i.e., with reduced sensitivity thresholds) and
tanopia or certain retinal conditions such as diabetic areas with absolute defects (i.e., with a sensitivity thresh-
retinopathies, retinal detachments and retinoschisis. old of 0 dB, where the maximum stimulus intensity of
Because these pathologies affect a signiicant portion of the perimeter cannot be seen). This information is often
the visual ield and often contain a meaningful number of clinically suficient to identify diseases whose diagnosis
absolute defects, quantitative testing with a reasonably is based on the shape of the defect rather than on small
dense test pattern can be too time-consuming and conse- changes in sensitivity.
quently lead to unreliable results in some patients due to

QUALITATIVE TEST WITH 2LT STRATEGY VS QUANTITATIVE TEST

QUALITATIVE TEST QUANTITATIVE TEST

2 LT strategy Dynamic strategy
12 07 pattern 12 07 pattern
9 3 9 3
6 6
+
+
+ +
+
+ +
+ + +
+ + +
+ + +
+ + + +
+ +
+ + +
+ + + + + + + +
+ + + + + + +
+
+ + + + + +
+ + +
+ +
+ + + + +
+ + + + + +
+ + + +
+ +
+ +
+ + +
+ +
+ +
+
+ +

FIGURE 6-9 The q ualitative 2LT strategy allows distinction of areas of normal vision and relative and absolute defects with
minimal test duration (left) and provides valuable information about the shape of defects. Q uantification of the same test pattern
with the dynamic strategy reveals the same pattern as well as detailed information about the sensitivity thresholds, but at the
expense of a longer test (right). In this example, because the visual field shows an absolute defect, the amount of information
provided by the 2LT strategy is comparable to the more detailed information provided by the q uantitative dynamic strategy.
Qualitative strategies 95

The 2LT strategy starts with the presentation of a stim- seen, it is marked as having an absolute defect (repre-
ulus 4dB below the normal sensitivity threshold at each sented by a “█” sign).
location. When this stimulus is seen, it is designated as
normal (represented by a “+” sign). When this stimulus is Note that typically more than one abnormal visual ield
not seen, a second stimulus is presented at a sensitivity location showing a disease-speciic pattern is required
threshold of 0 dB, which corresponds to the maximum to classify a visual ield as abnormal. For more detailed
stimulus intensity that the perimeter can present (FIG information on the distinction between normal and ab-
6-10). If this is seen, the location is marked as having a normal visual ields, see FIG 7-9, 7-10, 8-14 and 8-15.
relative defect (represented by a “□” sign) and if it is not

2-LEVEL TEST STRATEGY

Do you see? Normal visual Relative Absolute

field location defect defect

Normal

Stimulus
presented at
4dB below
Relative defect normal
sensitivity
threshold
= Seen

= Not seen

Absolute defect 0 dB 0 dB 0 dB

FIGURE 6-10 W ith the 2LT strategy, the visual field is divided into areas of normal visual field results, relative defects and
absolute defects.
96 Chapter 6 | Selecting a test strategy

RECOMMENDATIONS ON KEY
EXAMINATION PARAMETERS
There is always a trade-off between test duration and recommended combinations of test patterns and strat-
accuracy, but depending on the pathology or visual abil- egies for a variety of visual ield testing situations that
ity test performed, certain test parameter combinations maximize clinical information and minimize test duration.
offer better trade-offs than others. TABLE 6-3 presents

RECOMMENDED TEST PATTERN AND STRATEGY COMBINATIONS TABLE 6-3

TEST PATTERN RECOMMENDED STRATEGIES

GLAUCOMA/CENTRAL FIELD G, 32, 30-2, 24-2 Dynamic or TOP

MACULA M, 10-2 Dynamic or TOP

FULL FIELD (NEURO, RETINA) 07 Dynamic or 2LT

FOVEA F Dynamic

BLIND SPOT B 1LT

LOW VISION M, G, 07 depending on pathology Low Vision

SCREENING FOR Screening 28 Screening-P95

ABNORMAL VISION

DRIVING Esterman Fixed parameters

(1LT, stimulus duration 500 ms)

German Legal Driving Fixed parameters

(Führerscheingutachten FG) (2LT, stimulus duration 200 ms)

BLEPHAROPTOSIS BT 1LT

BLINDNESS BG Fixed parameters

(1LT, stimulus duration 500 ms)

This does not mean that these settings are the best for close to each other, it can only be used with the suficient-
each visual ield test; an expert user may prefer other ly dense central 30° and macula test patterns; 2) legally
combinations for certain situations. Therefore, Octopus prescribed ability tests such as the Esterman test are
perimeters offer the lexibility to customize examination offered only with their standardized settings to ensure
parameters. However, there are two exceptions: 1) because that the legal requirements are met.
the TOP strategy requires test locations to be relatively
References 97

REFERENCES
1. Bebie H, Fankhauser F, Spahr J. Static perimetry: strategies. Acta Ophthalmol (Copenh). 1976; 54:325-38.
2. Spahr J. Optimization of the presentation pattern in automated static perimetry. Vision Res. 1975;15:1275-1281.
3. Gonzáles de la Rosa M, Morales J, Dannheim F, et al. Multicenter evaluation of tendency-oriented perimetry (TOP)
using the G1 grid. Eur J Ophthalmol. 2003;13:32-41.
4. Weber J, Klimaschka T. Test time and eficiency of the dynamic strategy in glaucoma perimetry. Ger J Ophthalmol.
1995;4:25-31.
5. Weber J. A new strategy for automated static perimetry. Fortschr Ophthalmol. 1990;87:37-40.
6. Maeda H, Nakaura M, Negi A. New perimetric threshold test algorithm with dynamic strategy and tendency oriented
perimetry (TOP) in glaucomatous eyes. Eye (Lond). 2000;14:747-751.
7. Zein WM, Bashshur ZF, Jaafar RF, Noureddin BN. The distribution of visual ield defects per quadrant in standard
automated perimetry as compared to frequency doubling technology perimetry. Int Ophthalmol. 2010;30:683-689.
8. Zulauf M, Fehlmann P, Flammer J. Perimetry with normal Octopus technique and Weber 'dynamic' technique. Initial
results with reference to reproducibility of measurements in glaucoma patients. Ophthalmologe. 1996;93:420-427.
9. Wall M, Woodward KR, Doyle CK, Artes PH. Repeatability of automated perimetry: a comparison between standard
automated perimetry with stimulus size III and V, matrix, and motion perimetry. Invest Ophthalmol Vis Sci. 2009;50:974-979.
10. Gardiner SK, Swanson WH, Goren D, Mansberger SL, Demirel S. Assessment of the reliability of standard automated
perimetry in regions of glaucomatous damage. Ophthalmology. 2014:121:1359-1369.
11. King AJ, Taguri A, Wadood AC, Azuara-Blanco A. Comparison of two fast strategies, SITA Fast and TOP, for the assessment
of visual ields in glaucoma patients. Graefes Arch Clin Exp Ophthalmol. 2002;240:481-487.
12. Morales J, Weitzman ML, Gonzáles de la Rosa M. Comparison between Tendency-Oriented Perimetry (TOP) and Octopus
threshold perimetry. Ophthalmology. 2000;107:134-142.
13. Wadood AC, Azuara-Blanco A, Aspinall P, Taguri A, King AJ. Sensitivity and speciicity of frequency-doubling technology,
tendency-oriented perimetry, and Humphrey Swedish interactive threshold algorithm-fast perimetry in a glaucoma
practice. Am J Ophthalmol. 2002;133:327-332.
14. Morales J, Brown SM. The feasibility of short automated static perimetry in children. Ophthalmology. 2001;108:157-162.
15. Gonzalez-Hernandez M, Morales J, Azuara-Blanco A, Sanchez JG, de la Rosa MG. Comparison of diagnostic ability between
a fast strategy, tendency-oriented perimetry, and the standard bracketing strategy. Ophthalmologica. 2005;219:373-378.
16. Scherrer M, Fleischhauer JC, Helbig H, Johann Auf der Heide K, Sutter FK. Comparison of tendency-oriented perimetry
and dynamic strategy in Octopus perimetry as a screening tool in a clinical setting: a prospective study. Klin Monbl
Augenheilkd. 2007;224:252-254.
17. Pierre-Filho Pde T, Schimiti RB, de Vasconcellos JP, Costa VP. Sensitivity and speciicity of frequency-doubling technology,
tendency-oriented perimetry, SITA Standard and SITA Fast perimetry in perimetrically inexperienced individuals.
Acta Ophthalmol Scand. 2006;84:345-350.
18. Anderson AJ. Spatial resolution of the tendency-oriented perimetry algorithm. Invest Ophthalmol Vis Sci. 2003;44:
1962-1968.
19. Esterman B. Functional scoring of the binocular ield. Ophthalmology. 1982;89:1226-1234.
20. Siatkowski RM, Lam BL, Anderson DR, Feuer WJ, Halikman AM. Automated suprathreshold static perimetry screening for
detecting neuro-ophthalmologic disease. Ophthalmology. 1996;103:907-917.
21. Takahashi N, Hirasawa K, Hoshina M, Kasahara M, Matsumura K, Shoji N. Diagnostic ability and repeatability of a new
supra-threshold glaucoma screening program in Standard Automated Perimetry. Transl Vis Sci Technol.
2017;doi: 10.1167/tvst.6.3.7.
22. Turpin A, Myers JS, McKendrick AM. Development of visual ield screening procedures: a case study of the Octopus
perimeter. Transl Vis Sci Technol. 2016; doi: 10.1167/tvst.5.3.3.
 99

CHAPTER 7
OVERVIEW OF VISUAL FIELD
REPRESENTATIONS
INTRODUCTION
Perimetry determines sensitivity thresholds through- For these reasons, Octopus perimeters offer several re-
out the visual ield. However, it can be challenging to presentations that are based on the measured sensitivity
correctly interpret the raw data in clinical practice be- thresholds, but highlight speciic aspects of the visual
cause 1) normal sensitivity thresholds vary with age ield, in order to support clinical decision-making. In
and eccentricity of test location; 2) visual ield testing this chapter, a systematic presentation of all visual ield
contains a subjective component due to the patient de- representations and indices is offered, with their deini-
cision processes, which contributes to luctuation; 3) tions, design and relationships. While a detailed under-
both visual ield location and disease severity inluence standing of these characteristics is not necessary for
fluctuation; and 4) in some patients, more than one correct clinical interpretation, some readers will ind
disease may be present. For more information on these this information useful. The clinical meaning and inter-
points, see Chapter 2. pretation of these same visual ield representations are
subsequently discussed in a clinical step-by-step work-
low in Chapter 8, which also includes several examples.

RELATIONSHIP AMONG OCTOPUS

VISUAL FIELD REPRESENTATIONS
Most visual ield representations on Octopus perimeters the inluence of diffuse or widespread defects). FIG 7-1
are based on the following three key representations: provides an overview of these relationships.
1) Values (the sensitivity thresholds); 2) Comparisons
(the comparison of the sensitivity thresholds with age- In addition, Octopus perimeters determine several indi-
matched normative data); and 3) Corrected Comparisons cators of visual ield reliability, to assess whether a visual
(the comparison of the sensitivity thresholds with age- ield test is trustworthy or not. These are presented at
matched normative data, with a correction that eliminates the end of this chapter.
10 0 Chapter 7 | O verview of visual field representations

RELATIONSHIP AMONG DIFFERENT VISUAL FIELD REPRESENTATIONS

SENSITIVITY THRESHOLDS

Normative Values
26 25

27 26 27 27 26 26

29 29
28 29 29 27
28 31 31 31 31
28 32 32 31 28 27
31 33 33 32
35
32 33 33 32
29 32 33 31 28 27
28 31 32 32 31
29 30 30 29
31 31

28 30 30 29 28 26

29 28

- (Measured )Values Grayscale (Values)

17 17

19 23 12 14 21 1

7 19
15 18 25 5
16 9 15 24
25
24
22
28 16
30
11
1
1
MS
23
24
28
31 30
28
28
30 25 21 (Mean Sensitivity)
18 29 27 29 29
21 27 26 25
26 28

18 22 23 23 23 19

21 24

= SENSITIVITY LOSS
Comparisons Grayscale (Comparisons) Probabilities Cluster Analysis
9 8

8 + 15 13 5 25
15.8
22 10
13 11 + 22 11.3

12 22 16 7
+ 10 21 30 9.1 24.9
7 5 17 31 9.7
5
8 + + +
6 + 5 + + 6 4.4
8.3 2.7
10 + 5 + +
8 + + +
5 +
5.8
3.5
10 8 7 6 5 7

8 +

Defect Curve Polar Analysis

1
Rank
59
MD
-5
(Mean Defect)
0
5%
sLV
(square root
Defect (dB)

5 S

10 95%
30
[dB]
20 10 N
I
T of Loss Variance)
15
DD
20
(Diffuse Defect)
25
LD
(Local Defect)
Diffuse Defect
-
DD

= LOCAL SENSITIVITY LOSS

Corrected Comparisons Corrected Grayscale (CO) Corrected Probabilities Corrected Cluster Analysis
+ +

+ + 10 8 + 20
10.4
16 5 5.9
8 6 + 17
7 16 10 +
3.7 19.5
+ + 15 24 4.3
+ + 12 26
+
+ + + + +
+ + + + + +
2.9 +
5 + + + +
+ + + +
+ +
+
+
5 + + + + +

+ +

FIGURE 7-1 All visual field representations are based on the measured sensitivity thresholds (i.e., Values) and are mostly
compared to age-matched normative data (top), resulting in representations that show sensitivity loss (center). Some
representations also only display local sensitivity loss (bottom) because they are additionally corrected to eliminate the
influence of diffuse or widespread defects.
Representations displaying sensitivity thresholds 101

REPRESENTATIONS DISPLAYING
SENSITIVITY THRESHOLDS
Some representations display sensitivity thresholds values. The key representations and their relationship
as they are measured, without reference to normal are shown in FIG 7-2.

VALUES REPRESENTATIONS DISPLAY SENSITIVITY THRESHOLDS

HILL OF VISION ~ VALUES ~ GRAYSCALE (Values)

3D map 2D numerical map 2D color map
Sensitivity
threshold 17 17

19 23 12 14 21 1
Superior
Blind spot 7 19
Fixation 15 18 25 5
16 9 15 24
25 22 11 1
24 28 16 1
30
Temporal

24 31 30 28
70˚ 80˚ 90˚ 23 28 28 30 25 21
Nasal

18 29 27 29 29
21 27 26 25
26 28

18 22 23 23 23 19

21 24
Inferior

FIGURE 7-2 The Values and Grayscale of Values representations are two-dimensional maps of the hill of vision. They both
display sensitivity thresholds as either numerical maps (Values) or color maps (Grayscales). Note that the hill of vision is not
available as a representation on Octopus perimeters.

VALUES
The Values representation shows the sensitivity This representation is of limited diagnostic value, due to
thresholds at each test location and is presented in FIG the dependence of sensitivity thresholds on patient age
7-3. It represents the raw data of visual ield testing and and eccentricity of test location, as shown in FIG 2-9.
is a two-dimensional numerical map of a patient’s hill
of vision. Sensitivity thresholds are displayed in dB and
absolute defects are displayed using a “∎” symbol.
10 2 Chapter 7 | O verview of visual field representations

VALUES
17 17

19 23 12 14 21 1

7 19
15 18 25 5
16 9 15 24
25 22 11 1 7 Sensitivity threshold [dB]
24 28 16 1
30
24 31 30 28 Absolute defect
23 28 28 30 25 21 (i.e., Sensitivity threshold 0 dB)
18 29 27 29 29
21 27 26 25
26 28

18 22 23 23 23 19

21 24

FIGURE 7-3 The Values representation displays sensitivity thresholds in dB. Absolute defects with a sensitivity threshold
of 0 dB are displayed using a “∎” symbol.

GRAYSCALE OF VALUES
The Grayscale of Values representation displays the same Even though a color scale is used, the representation has
information as the Values representation (i.e., sensitivity kept its historic name (i.e., Grayscale), which was given at
thresholds), but as a two-dimensional color map, as shown a time when no color screens or printers were available.
in FIG 7-4. Each color represents sensitivity thresholds
within a range of 5 dB. White represents sensitivities of The color representation allows for a more intuitive
36 – 40 dB, while black represents the other end of the assessment of the three-dimensional shape of the hill of
scale, showing sensitivity thresholds of 0 dB. Areas be- vision than the numerical Values representation. How-
tween test locations are interpolated (i.e., the gaps between ever, the limitations of the Values representation also
test locations are illed with “probable” information). apply to the Grayscale of Values representation.

GRAYSCALE (VALUES)
Sensitivity
threshold
[dB]

36..40
31..35
26..30
21..25
16..20
11..15
6..10
1..5
0

FIGURE 7-4 The Grayscale of Values representation displays sensitivity thresholds on a color map. Each color represents a
range of 5 dB, with white showing the highest sensitivity and black representing absolute defects.
Representations based on comparisons with normal 103

REPRESENTATIONS BASED ON
COMPARISONS WITH NORMAL
COMPARISONS
The Comparisons representation allows direct assessment test locations. For that reason, it is the most widely used in
of the shape and magnitude of disease-related change in clinical practice, and most visual ield representations are
sensitivity. In contrast to the Values representation, its in- based on it.
terpretation is independent of the age and eccentricity of

COMPARISONS REPRESENTATION DISPLAYS DEVIATIONS FROM THE NORMAL VISUAL FIELD

NORMATIVE VALUES (MEASURED) VALUES COMPARISONS (TO NORMAL)

Normal sensitivity threshold Measured sensitivity threshold Sensitivity loss

26 25 17 17 9 8

27 26 27 27 26 26 19 23 12 14 21 1 8 + 15 13 5 25

29 29 7 19 22 10
28 29
29 29 27 15 18 25 5 13 11 + 22
28 31 31 31 31 16 9 15 24 12 22 16 7
28 32 32 31 28 27 25 22 11 1 + 10 21 30
31 33 33 32 24 28 16 1 7 5 17 31
32
35
33 33 32
- 24
30
31 30 28
= 8
5
+ + +
29 32 33 31 28 27 23 28 28 30 25 21 6 + 5 + + 6
28 31 31 18 29 29 10 + 5 + +
32 32 27 29
29 30 30 29 21 27 26 25 8 + + +
31 31 26 28 5 +

28 30 30 29 28 26 18 22 23 23 23 19 10 8 7 6 5 7

29 28 21 24 8 +

Sensitivity
threshold
Comparisons

Normative Values
of 20-year-olds

Measured Values
of a 20-year-old

FIGURE 7-5 The Comparisons representation calculates the deviation of the measured Values (sensitivity thresholds) from
the Values of an average normal person of the same age (normal sensitivity threshold at each location obtained from a
normative database).
10 4 Chapter 7 | O verview of visual field representations

The Comparisons representation is deined as the individ- Deviations smaller than 5 dB in magnitude are displayed
ual deviation from the average normal visual ield (stem- with “+” symbols, because as a rule of thumb, they can be
ming from the normative database) of the respective age considered to be approximately within the normal range
group. The difference in the normative value minus the of luctuation within the central 30 degrees of the visual
measured value at each test location is also termed sen- ield. Consequently, these small numerical values are not
sitivity loss, loss value or defect value. This principle is meaningful for the interpretation of the visual ield. Test
shown in FIG 7-5. More information on normative Values locations with a sensitivity threshold of 0 dB have reached
is given in BOX 2B. the loor of perimetric testing and are marked with a “∎”
symbol.
Deviations from a normative visual ield are displayed for
each location in dB. While the Comparisons are calculated Similar representations in non-Octopus devices are alter-
at all visual ield locations, their numerical values are not natively called defect map, total deviation (see TABLE 12-5)
necessarily presented at all locations, as shown in FIG 7-6. or deviation from normal.

COMPARISONS
9 8

8 + 15 13 5 25

22 10
13 11 + 22
12 22 16 7
+ Sensitivity loss < 5 dB
+ 10 21 30
7 5 17 31
5 22 Sensitivity loss [dB]
8 + + +
6 + 5 + + 6
Absolute defect
10 + 5 + + (i.e., Sensitivity threshold 0 dB)
8 + + +
5 +

10 8 7 6 5 7

8 +

FIGURE 7-6 The Comparisons representation allows for a direct assessment of the magnitude and location of a patient’s
sensitivity loss in dB. A deviation from a normal sensitivity threshold smaller than 5 dB is marked with a “+” symbol, and an
absolute defect with a sensitivity threshold of 0 dB is displayed with a “∎” symbol.
Representations based on comparisons with normal 105

GRAYSCALE OF COMPARISONS
The Grayscale of Comparisons is used clinically to intui- based on the Comparisons representation, it is indepen-
tively assess the magnitude and shape of sensitivity loss. dent of both patient age and eccentricity of test locations.
It is also useful for patient education because it is easy to A color scale is used to display sensitivity loss in % in rela-
understand. tion to a normal visual ield, with different colors used for
different levels of change in sensitivity. For example, a 0%
It is a color map in which the areas between test locations to 10% change in sensitivity is displayed in white, 47% to
are interpolated (i.e., the gaps in between test locations 58% sensitivity loss is shown in green, and 95% to 100%
are illed with “probable” information) (FIG 7-7). Since it is change in sensitivity is displayed in black.

GRAYSCALE (COMPARISONS)

Sensitivity loss
[% of normal]
0..10
11..22
23..34
35..46
47..58
59..70
71..82
83..94
95..100

FIGURE 7-7 The Grayscale of Comparisons representation is a color map showing sensitivity loss in relation to a normal
visual field. It allows for assessment of the depth and shape of sensitivity loss and is also useful for patient education.

There is an inverse relationship between the sensitivity the Grayscales, similar colors are used to display close to
thresholds displayed in the Grayscale of Values and the normal visual ields or fully defective visual ields. Since
sensitivity loss displayed in the Grayscale of Comparisons. the Values scale is absolute, showing ranges in dB, and the
In other words, a high sensitivity threshold means that Comparisons scale is relative, showing visual ield loss in
there is a small, or no loss of sensitivity (i.e., virtually no percent, the patterns show marginal differences. FIG 7-8
difference from normal). To facilitate the interpretation of demonstrates this relationship.
10 6 Chapter 7 | O verview of visual field representations

INVERSE RELATIONSHIP BETWEEN VALUES AND COMPARISONS REPRESENTATIONS

High sensitivity Low sensitivity

(MEASURED) VALUES COMPARISONS (TO NORMAL)
threshold [dB] loss [0 dB]

17 17 7 7

19 23 12 14 21 1 7 + 14 12 + 24

7 19 21 9
15 18 25 5 12 10 + 21
16 9 15 24 11 20 14 5
25 22 11 1 + 8 20 20
24 28 16 1 6 + 16 30
30 +
24 31 30 28 6 + + +
23 28 28 30 25 21 5 + + + + 5
18 29 29 9 + + + +
27 29
21 27 26 25 7 + + +
26 28 + +

18 22 23 23 23 19 9 6 5 5 + 6

21 24 6 +

Low sensitivity High sensitivity

threshold 0 [dB] loss [dB]

GRAYSCALE (Values) GRAYSCALE (Comparisons)

Sensitivity Sensitivity loss

threshold [% of normal]
[dB]

36..40 0..10
31..35 11..22
26..30 23..34
21..25 35..46
16..20 47..58
11..15 59..70
6..10 71..82
1..5 83..94
0 95..100

FIGURE 7-8 There is an inverse relationship between the Grayscale of Values and the Grayscale of Comparisons represen-
tations. Yet because an inverse color scale is used, the graphics appear similar, thereby facilitating interpretation (light colors
indicate normal areas and darker colors indicate areas with defects). As the Grayscale of Values is an absolute scale (dB) and
the Grayscale of Comparisons is a relative scale (percent of normal), the shapes and depths are comparable, but not identical.

It should be noted that the Grayscale of Comparisons pro- Grayscale of Values also shows more severe loss in the
vides more clinically meaningful information than the peripheral area compared to the central area, due to
Grayscale of Values because it is not affected by patient the effect of eccentricity. The Grayscale of Comparisons
age or the eccentricity of test location, and thus shows a adjusts for age and eccentricity. For clinical purposes, it
patient’s visual ield loss. When comparing Grayscales is therefore recommended to always use the Grayscale
of Values for younger and older controls, the Grayscales of of Comparisons, which is part of the standard printouts
the older person are likely to show more loss, because of Octopus perimeters.
normal age effects are not taken into account. The
Representations based on comparisons with normal 107

PROBABILITIES
The Probabilities representation is used clinically to dis- data. More precisely, they show the probability that a given
tinguish between normal and abnormal visual ield loca- sensitivity threshold would be obtained at the respective
tions. This representation is needed because normal luc- location for a person of the same age as the patient with a
tuation is not uniformly distributed across the visual ield; normal visual ield.
instead, it is smaller in the center and larger towards the
peripheral visual ield. It is therefore not possible to use For example, a person with a normal visual ield has a
the same numerical cut-off point (e.g., 6 dB sensitivity loss, high probability of having little to no sensitivity losses. But
representing an abnormal visual ield location) for all there is also a small probability that a person with a nor-
visual ield locations. mal visual ield would obtain some sensitivity loss. FIG 7-9
illustrates this and also displays examples of patient visual
The Probabilities representation uses symbols that are ields in relation to normal visual ields.
associated with the statistical distribution of normative

DISTRIBUTION OF SENSITIVITY THRESHOLDS OF THE NORMAL POPULATION

ADVANCED MODERATE EARLY GLAUCOMA NORMAL

GLAUCOMA GLAUCOMA GLAUCOMA SUSPECT Person E
Person A Person B Person C Person D

Number
of people

High No
1% 5% 0 dB
sensitivity (Average sensitivity
loss 0.5% 2% normal value) loss
p < 2%

p < 5%

p > 5%
p < 1%

p < 0.5%

FIGURE 7-9 The distribution displayed in blue indicates the range of possible sensitivity losses at a specific test location
and the probability of these being obtained for a person with a normal visual field. It ranges from no sensitivity loss (right) to
high sensitivity loss (left), with an average normal value of 0 dB. While it is highly unlikely that a person with a normal visual
field would obtain a sensitivity loss at a specific test location similar to those seen on the left of the p < 0.5% mark, a small
proportion (0.5%) of the test locations of normal subjects do give these results. The top part of the figure illustrates the results
typically obtained for patients at different stages of the disease, at a majority of test locations. Note that for easier readability
the distribution is not drawn to scale.
10 8 Chapter 7 | O verview of visual field representations

The Probabilities representation shows the probability (p < 5%): there is a smaller than 5% (and larger than
(p) that a normal population shows a given sensitivity 2%) chance that a person with a normal visual ield
loss. When the sensitivity loss is high, the likelihood that would show this sensitivity loss.
it comes from a person with a normal visual ield is low.
From a clinical perspective, one could assume that it is (p < 2%): there is a smaller than 2% (and larger than
more likely that the sensitivity loss comes from the pa- 1%) chance that a person with a normal visual ield
tient population. would show this sensitivity loss.

Increasingly darker symbols are used to show the de- (p < 1%): there is a smaller than 1% (and larger than
creasing probability that a person with a normal visual 0.5%) chance that a person with a normal visual ield
ield would show a given sensitivity loss at a certain test would show this sensitivity loss.
location (FIG 7-10):
(p < 0.5%): there is a smaller than 0.5% chance that a
(p > 5%): there is a high probability that a person with person with a normal visual ield would show this sen-
a normal visual ield would show this sensitivity loss. sitivity loss.

PROBABILITIES
Probability that a person
with a normal visual field
shows this result

p > 5%
p < 5%
p < 2%
p < 1%
p < 0.5%

FIGURE 7-10 The various symbols on the Probabilities representation show the likelihood that a given sensitivity loss would
be obtained for a person with normal vision. For example, the black square (p < 0.5%) indicates that while it is possible that a
person with normal vision could obtain that defect value, the probability of this occurring is very small (less than 0.5%).

It should be noted that caution is essential in the clinical for 3 locations). The same is true for a level of signiicance
interpretation of the Probabilities representation. This is of p < 2%, which by deinition occurs in 1 out of 50 test
due to the fact that a small number of isolated test loca- locations (i.e., on average for one location in the G pattern).
tions at a level of signiicance of p < 5% is likely to show up, A level of signiicance of p < 0.5% is even expected to occur
even in normal visual ields. For example, in a G pattern, in one out of three normal visual ields. More information
which has 59 test locations, by deinition a p value of p < on how to clinically interpret the Probabilities representa-
5% should occur in 1 out of 20 locations (i.e., on average tion is given in FIG 8-15.
Representations based on comparisons with normal 109

DEFECT CURVE
The Defect Curve (also called Bebie Curve¹) is a graphical and makes it possible to distinguish between local and
representation that alerts the clinician to the presence of diffuse defects at a glance. For more information on its
diffuse defects. It provides a summary of the visual ield design, see BOX 7A.

DESIGN OF THE DEFECT CURVE BOX 7A

The Defect Curve is based on the Comparisons representation (i.e., the sensitivity loss in comparison to
the normal visual ield). The Comparisons are irst ranked according to their magnitude, from the small-
est to the largest defect. The Defect Curve is drawn by plotting the defects (Y-axis) as a function of their
rank (X-axis). To give an example, the 28th smallest defect in the igure below is about 7 dB. The Y-axis
ranges from -5 to 25 dB. It must be noted that negative values indicate that there was no defect com-
pared to normal and that the sensitivity is higher than the average normal value. This typically happens
randomly at a few locations in every normal visual ield, and therefore the average normal visual ield
shows negative values in the irst ranks.
This procedure generates the Defect Curve, which by deinition always starts from the top left and
moves to the bottom right. Note that spatial information is lost. The average normal Defect Curve is
displayed to serve as a reference, lanked by upper and lower limits that show the area in which 90% of
normal Defect Curves lie.

DEFECT CURVE

COMPARISONS (TO NORMAL)

Y-axis:
Defects
in dB
Average normal
9 8 -5 Defect Curve
8 + 15 13 5 25
0
22 10 + 5%
13 11 + 22 Normal
12 22 16 7 5 band of
7 Defect
+ 10 21 30 Curve
7 5 17 31
5 10 95%
8 + + +
6 + 5 + + 6 13
10 + 5 + +
15
8 + + +
5 + Defect Curve
10 8 7 6 5 7 20 22

8 +
25
1 59 X-axis:
Ranks

The Defect Curve is a representation that ranks individual defects according to their size from left to right.
Normal visual ields have a Defect Curve within the normal band, while the Defect Curve in abnormal visual
ields lies outside the normal band.

The interpretation of the Defect Curve is straightforward. instances, a combination of diffuse (or widespread) loss
Parallel downward shifts of the Defect Curve represent and local visual ield loss is present. FIG 7-11 shows these
diffuse defects; a drop on the right-hand side of the four main situations, while more examples are provided
curve represents local defects and Defect Curves within in FIG 8-10.
the normal band are considered to be normal. In many
110 Chapter 7 | O verview of visual field representations

DEFECT CURVE

NORMAL DIFFUSE DEFECT LOCAL DEFECT LOCAL & DIFFUSE DEFECT

Defect Curve within normal Parallel downward shift of Drop of Defect Curve Parallel downward shift on
band Defect Curve on the right the left and drop on the right
Rank Rank Rank Rank
1 59 1 59 1 59 1 59

-5 -5 -5 -5

0 0 0 0
5% 5% 5% 5%
Defect (dB)

Defect (dB)

Defect (dB)

Defect (dB)
5 5 5 5

10 95% 10 95% 10 95% 10 95%

15 15 15 15

20 20 20 20

25 25 25 25

FIGURE 7-11 The Defect Curve is helpful to distinguish intuitively between diffuse and local sensitivity loss. The four main situ-
ations: normal, diffuse defect, local defect, and local plus diffuse defect, are shown here.

CLUSTER ANALYSIS
Cluster Analysis has been designed specifically for For Cluster Analysis, visual ield locations corresponding
glaucoma and is very sensitive to detection of subtle to the same retinal nerve iber layer (RNFL) bundle are
glaucomatous defects. It capitalizes on the fact that typical grouped and used to calculate a mean cluster defect (Clus-
glaucomatous defects consist of a cluster of adjacent de- ter MD). In total, the visual ield is divided into ten clusters,
fective visual ield locations that correspond to the path as shown in FIG 7-12.
followed by the retinal nerve iber bundles in the retina.²

CLUSTER ANALYSIS DISPLAYS TEN CLUSTER MEAN DEFECTS

COMPARISONS CLUSTER ANALYSIS

9 8

8 + 15 13 5 25
15.8
22 10 11.3
13 11 + 22
12 22 16 7
21 9.1 24.9
+ 10 30 9.7
7 5 17 31
5
8 + + + 4.4
6 + 5 + + 6
8.3 2.7
10 + 5 + +
8 + + +
5 +
5.8
3.5
10 8 7 6 5 7

8 +

FIGURE 7-12 The Cluster Analysis displays 10 visual field clusters that spatially correlate with retinal nerve fiber bundles. In
each Cluster, the average sensitivity loss is calculated and presented as a Cluster Mean Defect (MD). In this example, the
superior paracentral cluster is highlighted in red and its corresponding sensitivity losses are written in red font.
Representations based on comparisons with normal 111

The concept of Probabilities, as presented in the sec- has a signiicance of p < 5% (and p > 1%) and a cluster
tion about the Probabilities representation, is also MD in red font has a signiicance of p <1%. The latter is
used in Cluster Analysis (FIG 7-13). Cluster MDs with a thus more likely to be abnormal than the former. Addi-
signiicance of p > 5% are displayed with a “+” symbol tionally, the degree of shading indicates the deviation
and indicate that for an average person with a normal from normal values for the clusters, with lighter shad-
visual ield there is a high probability of this cluster ing representing lower cluster MDs, and darker shading
MD value being obtained. A cluster MD in orange font representing higher cluster MDs.

CLUSTER ANALYSIS

15.8
11.3

Cluster MD [dB]
9.1 24.9
9.7 + p > 5%
4.4
2.7 p < 5%
8.3 2.7
8.3 p < 1%

5.8
3.5

FIGURE 7-13 The Cluster Analysis indicates the probability (p) of a normal person having a certain Cluster MD by displaying
the Cluster MD in red font for p < 1%, or in orange font for p < 5%. Clusters with p > 5% (not shown here) are displayed with a
“+” symbol.

A major advantage of Cluster Analysis is that it is more cluster.³ The normal ranges for Cluster MDs are therefore
sensitive to detection of signiicant early glaucomatous much smaller, with signiicant change being identiied
change than single point representations such as the Com- earlier.4-6, 15 For more information on the high sensitivity
parisons or Probabilities graphs. This is because single test of Cluster Analysis15 for glaucoma detection, see BOX 8B.
locations are subject to considerable normal luctuation.
The averaging procedure used in the Cluster Analysis sig- Additional information on the design of the Cluster Analy-
niicantly reduces the amount of luctuation within each sis is provided in BOX 7B.
112 Chapter 7 | O verview of visual field representations

BOX 7B DESIGN OF CLUSTER ANALYSIS

The Cluster Analysis is based on the distribution of retinal nerve ibers in the retina. To design the
Cluster Analysis, all test locations of the G pattern were superimposed over the RNFL map described by
Hogan et al.2 Next, visual ield locations were grouped into 22 sectors. Test locations whose respective
RNFL bundles entered the optic disc in close spatial proximity were grouped into the same cluster. This
procedure yielded clusters with 2 to 4 test locations. It was noted that the test locations in each cluster
were part of the same 5° sector at the optic disc.
Since some of the clusters contained too few test locations to signiicantly reduce variability, these 22
clusters were further grouped to yield the 10 clusters used in the Cluster Analysis. These 10 clusters
have been shown to correlate well with structural indings.7–10
The arithmetic mean of all defects within one cluster results in the Cluster Mean Defect (MD). This
number is displayed within each cluster. It should be noted that while the clusters are not strictly sym-
metrical, a symmetrical graph is used on the printout, for the sake of simplicity.

DESIGN OF CLUSTER ANALYSIS

GROUPING OF VISUAL 22 VISUAL 10 VISUAL

FIELD LOCATIONS FIELD CLUSTERS FIELD CLUSTERS
Based on entry of RNFL Each containing Combining the 22 clusters
bundles into optic disc 2 – 4 locations (at least 4 test
locations per cluster)

270

0 180

90

The ten Clusters used in the Cluster Analysis are generated by superimposition of the test pattern onto
an RNFL map and segmentation into sectors at the optic nerve head (left). Clustering of the visual ield
locations included in these sectors leads to 22 initial clusters in the G pattern (center), which are further
combined into 10 clusters (right).

By using the cluster boundaries deined for the G pattern, Cluster Analysis has been designed for the
32/30-2 and the 24-2 patterns. All cluster maps are based on the principle explained above.

CLUSTER ANALYSIS FOR DIFFERENT TEST PATTERNS

G 32/30-2 24-2

Cluster Analysis is available for the G, 32, 30-2 and 24-2 patterns. Note that the central test locations in the
G pattern and the two test locations inside the blind spot in the 30-2/24-2 patterns (test locations shown in
gray) are not included in any cluster.
Representations based on comparisons with normal 113

As with the interpretation of the Probabilities represen- in 50% of normal visual ields), and one cluster at p < 1 %
tations, however, some caution is essential in the clinical in one out of 10 normal visual ields (1 out of 10 clusters
interpretation of the Cluster Analysis representation. at p < 1% occurs in 10% of normal visual ields). A signif-
This is due to the fact that one cluster defect at a signif- icant cluster defect is thus far more clinically meaningful
icance of p < 5% is likely to show up in one out of two if it is spatially correlated with another signiicant cluster
normal visual ields (1 out of 10 clusters at p < 5% occurs defect, 5,6 or if it correlates with a structural defect.

POLAR ANALYSIS
The Polar Analysis has been designed speciically for Once the visual ield has been lipped across the hor-
glaucoma.11 It provides information about where struc- izontal axis, each sensitivity loss obtained from the
tural defects are to be expected at the optic disc, by dis- Comparisons representation is mapped onto the nerve
playing visual ield results using structural coordinates. iber that corresponds to it. The nerve iber projects to
It is based on the known relationship between structure the optic disc and enters at a speciic angle around the
and function and capitalizes on the fact that each visual optic disc. The angle of entry of each nerve iber is de-
ield location corresponds to a speciic retinal nerve termined and used to place each test location as a radial
iber bundle in the retina (i.e., a superior visual ield bar on the Polar Analysis representation. The length of
location corresponds to an inferior retinal location and the bar shows the sensitivity loss in dB from the Com-
a nasal visual ield location corresponds to a temporal parisons representation. Note that if two or more test
retinal location).² For more information on the rela- locations map onto the nerve ibers that enter at the
tionship between structure and function, see BOX 8C. same angle, the values of the corresponding test point
locations are averaged.11 To facilitate interpretation, a
Similar to the Cluster Analysis, the Polar Analysis is gray band ranging from +4 dB to -4 dB provides a rough
based on a superimposition of the test pattern onto indication of a normal range. The definitions of the
Hogan’s² RNFL map (FIG 7-14). Since the superior visual Polar Analysis are shown in FIG 7-15.
ield corresponds to the inferior retina, the visual ield
is irst lipped across the horizontal axis.
114 Chapter 7 | O verview of visual field representations

DESIGN OF THE POLAR ANALYSIS

VISUAL FIELD ORIENTATION

COMPARISONS
S
9 8

8 + 15 13 5 25

22 10
13 11 + 22
12 22 16 7
+ 10 21 30
7 5 17 31
T 5 N
8 + + +
6 + 5 + + 6
10 + 5 + +
8 + + +
5 +

10 8 7 6 5 7

8 +

STRUCTURAL ORIENTATION

1. Locate nerve fiber 2. Define nerve fiber 3. Draw polar bar at previously
entry site at optic disc entry angle at optic disc determined location
(Length corresponds to defect size)
4. Repeat for all test locations

270 270 S
30 20 10 N T
0 180 T N 0 180 T [dB]
I
90 90
105°

FIGURE 7-14 The Polar Analysis orients visual field results (top) like a structural result (bottom), flipping the results across
the horizontal meridian. It projects a sensitivity loss from the Comparisons chart (e.g., 13 dB, highlighted in red, top) along the
corresponding retinal nerve fibers on the retina to the optic disc (red circle, bottom left). At the nerve fiber entry site a red
bar is drawn at the angle at which the nerve fiber enters the optic disc (here 105°, bottom middle), with the length of the bar
corresponding to the magnitude of the sensitivity loss (i.e., 13 dB, bottom right). By repeating this procedure for all visual field
locations, the Polar Analysis is drawn (all red bars, bottom right). (S: Superior; I: Inferior; N: Nasal; T: Temporal)
Representations based on comparisons with normal, corrected for diffuse defects 115

POLAR ANALYSIS

Defect [dB]
• Length of bar indicates defect size [dB]
• Position along the optic disc represents
the entry angle of RNFL fibers associated
S to each test location
30 20 10
N T
[dB] Normal range
I

S Superior
I Inferior
N Nasal
T Temporal

FIGURE 7-15 The Polar Analysis displays sensitivity losses from the Comparisons chart as a projection onto the optic disc, to
allow for easy correlation with structural results. The length of the bars indicates the sensitivity loss in dB.

The Polar Analysis is a very useful tool to link structural well with structural results12 and usefully assists the
and functional results because it allows direct side-by- identiication of the spatially corresponding structural
side comparison of the structural and functional results, (RNFL) defects.
as can be seen in FIG 8-24. It has been shown to correlate

REPRESENTATIONS BASED ON
COMPARISONS WITH NORMAL,
CORRECTED FOR DIFFUSE DEFECTS
CORRECTED COMPARISONS
It is useful to analyze localized visual ield defects inde- representation. The correction applied to the Corrected
pendently of diffuse defects, which in many cases are Comparisons is based on the DD global index, which rep-
caused by cataract. To do so, the Comparisons, Grayscale resents the magnitude of diffuse defect. The DD is subtract-
of Comparisons, Probabilities and Cluster Analysis rep- ed from the sensitivity losses displayed in the Comparisons
resentations are all available in a corrected version. This representation. The DD is explained in detail in the section
corrected version removes diffuse or widespread defects on global indices. FIG 7-16 illustrates how the corrected rep-
and displays only localized visual ield loss. All “corrected” resentations are calculated.
representations are based on the Corrected Comparisons
116 Chapter 7 | O verview of visual field representations

CORRECTED COMPARISONS AND ITS RELATIONSHIP WITH OTHER CORRECTED REPRESENTATIONS

COMPARISONS CORRECTED COMPARISONS

9 8 + +

8 + 15 13 5 25 + + 10 8 + 20
10 5
22 10 16 5
13 11 + 22 8 6 + 17
12 22 16 7 7 16 10 +
+ 10 21 30 + + 15 24

6
7
8
+
5 17 31
5
+ +
5
+
+ + 6
- DD = 4.5 dB = +
+
+
+
+ 12 26
+
+ +
+
+
+ + +
10 + 5 + + 5 + +
+ +
8 + + + + + + +
5 + + +

10 8 7 6 5 7 5 + + + + +

8 + + +

GRAYSCALE (COMPARISONS) CORRECTED GRAYSCALE (CO)

PROBABILITIES CORRECTED PROBABILITIES

CLUSTER ANALYSIS CORRECTED CLUSTER ANALYSIS

15.8 10.4
11.3 5.9

24.9 9.1
3.7 19.5
9.7 4.3

4.4 +
2.7 8.3
2.9 +

5.8 +
3.5 +

FIGURE 7-16 The Corrected Comparisons representation is calculated by subtracting the magnitude of the diffuse defect expressed
in the DD index from each sensitivity loss in the Comparisons representation. It allows for the assessment of localiz ed visual field loss
without the influence of diffuse defects and is the basis for the calculation of all the corrected representations.
Representations based on comparisons with normal, corrected for diffuse defects 117

The Corrected Comparisons representation is similar to the Comparisons representation and uses the same symbols
to show sensitivity loss once the diffuse defect is removed (FIG 7-17).

CORRECTED COMPARISONS

+ +

+ + 10 8 + 20

16 5
8 6 + 17
7 16 10 +
+ Sensitivity loss < 5 dB
+ + 15 24
+ + 12 26
+ 16 Sensitivity loss [dB]
+ + + +
+ + + + + +
Absolute defect
5 + + + + (i.e., Sensitivity threshold 0 dB)
+ + + +
+ +

5 + + + + +

+ +

FIGURE 7-17 The Corrected Comparisons representation shows the magnitude of local sensitivity loss once the diffuse defect
is removed. It uses the same definitions as the Comparisons representation.

GRAYSCALE OF CORRECTED COMPARISONS

The Grayscale of Corrected Comparisons representation uses the deinitions of the Grayscale of Comparisons represen-
tation as shown in FIG 7-18. It displays sensitivity loss as a color map without diffuse defect.

GRAYSCALE OF CORRECTED COMPARISONS

Sensitivity loss
[% of normal]
0..10
11..22
23..34
35..46
47..58
59..70
71..82
83..94
95..100

FIGURE 7-18 The Grayscale of Corrected Comparisons uses the symbols of the Grayscale of Comparisons representation. It is based
on the Corrected Comparisons representation and thus displays data without diffuse defect.
118 Chapter 7 | O verview of visual field representations

CORRECTED PROBABILITIES
The Corrected Probabilities representation is very similar to the Probabilities representation and shows the probability that
a person with a normal visual ield shows this corrected sensitivity loss at various signiicance levels, as shown in FIG 7-19.

CORRECTED PROBABILITIES
Probability that a person
with a normal visual field
shows this result

p > 5%
p < 5%
p < 2%
p < 1%
p < 0.5%

FIGURE 7-19 The Corrected Probabilities representation uses the definitions of the Probabilities representation. It is based on
the Corrected Comparisons representation and displays data without diffuse defect.

CORRECTED CLUSTER ANALYSIS

The Corrected Cluster Analysis is very similar to the Cluster Analysis, but is based on the Corrected Comparisons. It shows
the probability that a person with a normal visual ield shows this corrected Cluster Mean Defect in dB at various signii-
cance levels, as shown in FIG 7-20.

CORRECTED CLUSTER ANALYSIS

10.4
5.9

Corrected Cluster MD [dB]

3.7 19.5
4.3 + p > 5%
+
+
2.9 p < 5%
2.9
5.9 p < 1%

+
+

FIGURE 7-20 The Corrected Cluster Analysis representation uses the definitions of the Cluster Analysis representation. It is
based on the Corrected Comparisons representation and displays data without diffuse defect.
Global indices 119

GLOBAL INDICES
Global indices are useful numerical summaries of the entire assess the severity of visual ield loss and 3) are helpful in
or an aspect of the visual ield.13 They 1) provide a summary the evaluation of change over time. The formulae used to
of the status of the visual ield, 2) are useful to objectively calculate each global index are shown in TABLE 7-1 .

GLOBAL INDICES AVAILABLE FOR OCTOPUS PERIMETERS TABLE 7-1

INDEX FORMULA VARIABLES

MEAN N: Total number of test locations

SENSITIVITY
(MS) xi: Sensitivity threshold at test location i, or
mean of two repeated measurements xi1, xi2
at test location i

MEAN DEFECT ni: Normal value at test location i

(MD)
di: Sensitivity loss at test location i

SQUARE ROOT OF
LOSS VARIANCE
(sLV)

CORRECTED ME: Mean Error

SQUARE ROOT OF
LOSS VARIANCE
(CsLV)

MEAN SENSITIVITY (MS)

The Mean Sensitivity (MS) is the arithmetic mean of the Values and its diagnostic value is therefore limited because
sensitivity thresholds displayed in the Values representa- it is dependent on patient age and on the spatial distribution
tion. It represents a patient's average sensitivity to light with of the test locations.
respect to the locations that are tested. MS is based on the

MEAN DEFECT (MD)

The Mean Defect (MD) is the arithmetic mean of the sensi- assess visual ield severity.13 It is a key index used in the
tivity loss displayed in the Comparisons representation. It progression analysis available on Octopus perimeters (see
represents the average visual ield loss of a patient derived Chapter 9).
from the locations that are tested and is thus often used to
12 0 Chapter 7 | O verview of visual field representations

SQUARE ROOT OF LOSS VARIANCE (sLV)

The square root of Loss Variance (sLV) represents the (i.e., diffuse) or localized at some locations. The sLV
standard deviation of the individual defects at all visual index thus further summarizes the characteristics of a
ield locations and provides a measure of variability visual ield. The sLV index is large in inhomogeneous
across the visual ield.13 This index is useful because the visual ields (localized defects) and small in homoge-
Mean Defect (MD) does not provide any information neous visual ields (diffuse defects), as shown in FIG 7-21.
about whether visual ield loss is uniformly distributed

SQUARE ROOT OF LOSS VARIANCE (sLV)

DIFFUSE DEFECT LOCAL DEFECT

COMPARISONS COMPARISONS

9 9 8 +

5 8 11 10 5 5 8 5 6 6 8 +

8 10 17 10
+ 11 + + 15 13 10 +
+ 6 7 7 6 26 21 19 23 +
+ 5 7 7 + + 19 22 22 21 18 +
5 7 7 + 21 15 13 17
7 12
9 6 6 7 + 5 6 +
8 6 6 6 6 5 + + + + + +
5 9 5 + + +
7 + + +
9 15 5 5 + + + +
10 6 + +

7 8 8 6 5 5 + + + + + +

5 5 + +

MD 6.3 dB MD 6.5 dB
sLV 2.5 dB sLV 8.5 dB

26
23
22 22
15 21 21 21
19 19
18 sLV
11 11 17 17 8.5 dB
15 15
10 10 10 sLV 12 13
9 9 99 9
2.5 dB 11
10 10
8 8 8 8 8
7 7 7 7 7 7 7 7 7 7 MD 8 8 8 MD
6 6 6 6 66 6 66 6 6 6.3 dB 6 6 6 6.5 dB
5 55 5 5 55 5 5 5 5 5 5 5 5
+ + + + + + ++ ++ +
+ + ++
+ ++ + + + ++ + +
+
+ + + + + ++ +

FIGURE 7-21 The sLV provides a measure of the inhomogeneity of a visual field. This is illustrated in this figure, which shows
a homogeneous visual field with diffuse defect (left) and a heterogeneous visual field with localized defect (right). If the visual
field is homogeneous, the sensitivity losses at specific test locations (shown on the Y-axis in the bottom part of the figure) do
not deviate strongly from MD, and sLV is small (left). If the visual field is heterogeneous, some locations deviate strongly from
MD, and therefore sLV is large (right). Note that sLV is the standard deviation of the local defects and thus does not span the
full range of determined sensitivity losses.
Global indices 121

CORRECTED SQUARE ROOT OF LOSS VARIANCE (CsLV)

The Corrected square root of Loss Variance (CsLV) is The reliability index used for CsLV is Short-term Fluc-
similar to the sLV, with an added correction factor to tuation (SF), which is explained in detail in the section
account for the variability of patient responses that occurs about reliability indices. Note that CsLV is only displayed
during a perimetric test. It is a useful index to distin- if SF is actively determined during the visual ield test by
guish between a truly heterogeneous visual ield and repeated testing at all test locations.
a visual ield that is heterogeneous due to Short-term
Fluctuation.13

DIFFUSE DEFECT (DD)

DEFINITION OF DIFFUSE DEFECT (DD) BOX 7C

As shown in the section about the Defect Curve, diffuse defects result in a parallel downward shift of
the Defect Curve. The magnitude of that shift is measured by assessing the distance between the Defect
Curve and the average normal Defect Curve at a representative location along the curve. This generates
the index DD.
As the Defect Curve may not be fully parallel with the average normal Defect Curve, it is essential to
measure at a location that represents diffuse visual ield loss. DD is calculated from the 20th to the
27th percentile of the ranks. For the G pattern, which includes 59 test locations, this translates into
the range from the 12th to the 16th rank from the left. This area is neither too close from the left to be
meaningfully affected by random abnormally high sensitivity responses, nor too close to the right to
be meaningfully affected by local defects. To be less inluenced by variability, an average of the devia-
tions of the respective ranks from the median Defect Curve is used.

DIFFUSE DEFECT (DD)

Y-axis:
Defects in dB
Average normal
-5 Defect Curve

0
5%

5
Diffuse Defect
10 95%

15

20

25
1 12 16 59 X-axis:
Ranks

In the Defect Curve, all individual defects are ranked from 1 to the total number of test locations (e.g., the
59 locations of the G pattern are shown here). The DD is calculated from the magnitude of the downward
shift of the Defect Curve at the ranks from the 20th to the 27th percentile (for the G pattern, ranks 12 to 16).
122 Chapter 7 | O verview of visual field representations

The index DD allows quantiication of diffuse defect in ous section of this chapter. It is also used in the progres-
dB and is derived from the Defect Curve, as explained in sion analysis available on Octopus perimeters to identify
BOX 7C. It is mainly used to calculate the Corrected Com- the presence of diffuse progression (see Chapter 9).
parisons representation, which is discussed in the previ-

LOCAL DEFECT (LD)

The index LD allows quantification of the mean local available on Octopus perimeters to identify the presence
defect in dB and is also derived from the Defect Curve, as of local progression.
explained in BOX 7D. It is used in the progression analysis

BOX 7D DEFINITION OF LOCAL DEFECT (LD)

Any point on the Defect Curve outside normal limits represents an abnormal visual ield point. Shifting
down the average normal Defect Curve by the amount of the diffuse defect DD yields a curve represent-
ing the diffuse defect. Any further deviation of the individual Defect Curve downwards indicates local
defects. The local defect index LD is deined as the average of these deviations measured between the
14th and 59th ranks for the G pattern. In more general terms and also applicable to other test patterns,
the LD index is deined as the average of these deviations measured between the 23rd percentile of
ranks and the last rank.

LOCAL DEFECT (LD)

Y-axis:
Defects in dB
Average normal
-5 Defect Curve

0
5%

5
Diffuse Defect
10 95%

15
Local Defect
20

25
1 59 X-axis:
Ranks

The LD index represents the magnitude of the average local defect and is derived from the Defect Curve. It is
calculated from the deviation between the Diffuse Defect and the Defect Curve, as indicated by the red area.
Reliability indices 123

RELIABILITY INDICES
Due to the subjective component of perimetric testing, These are presented below with their respective formula,
unreliable visual ield results occur and it is essential shown in TABLE 7-2 at the end of this section. For more
to identify them in clinical practice. Octopus perime- information on how to clinically interpret reliability
ters provide several indicators of visual ield reliability. indices, see the section on reliability in Chapter 8.

FALSE POSITIVE (FP) ANSWERS

False positive (FP) answers are used to detect trigger- in the natural rhythm of perimetric testing in which
happy patients. These are patients who respond even no stimulus is presented. If a patient responds, this is
when no stimulus is presented. This type of patient marked as a false positive answer (FIG 7-22).
behavior occurs if patients do not understand the nature
of the test, or if they wish to positively inluence the result. The false positive rate is calculated as the ratio of false
positive answers to the total amount of positive catch
Positive catch trials are used to identify false positive an- trials presented. A false positive rate above 15% is high-
swers. Positive catch trials consist of a gap introduced lighted in orange color, and a false positive rate above
33% is highlighted in red color.

FALSE POSITIVE (FP) ANSWERS

Yes

Do you see
the stimulus?

Fixation
Target

FIGURE 7-22 False positive answers occur when patients respond even though no stimulus is presented. They are useful to
detect unreliable visual fields.
124 Chapter 7 | O verview of visual field representations

FALSE NEGATIVE (FN) ANSWERS

False negative answers are used to detect fatigue, loss of should be able to see these bright stimuli, and when they
attention and potential ixation loss during perimetric are missed, this is marked as a false negative answer
testing. (FIG 7-23).

Negative catch trials are used to identify false negative The false negative rate is calculated as the ratio of false
answers. Negative catch trials consist of stimuli that negative answers to the total amount of negative catch
are presented at a higher intensity than the patient has trials presented. A false negative rate above 15% is
previously seen. Patients who perform the test reliably highlighted in orange color, and a false negative rate
above 33% is highlighted in red color.

FALSE NEGATIVE (FN) ANSWERS

Yes No

Do you see Do you see

the stimulus? the stimulus?

Fixation Fixation
Target Target

FIGURE 7-23 False negative answers occur when patients do not respond to a stimulus of higher intensity (right) than a
stimulus they had previously seen at that location (left). A high false negative response rate can indicate an unreliable field
and may be an indicator of fatigue.
Reliability indices 125

RELIABILITY FACTOR (RF)

The Reliability Factor (RF) summarizes the false positive both false positive and false negative answers to the sum
and false negative answers. RF is calculated as the ratio of of positive and negative catch trials presented.

SHORT-TERM FLUCTUATION (SF)

The Short-term Fluctuation (SF) index provides a measure the deviations between the irst and second sensitivity
of the variability of patient responses that occurs during a thresholds are determined. SF is deined as the standard
perimetric test.13 In order to determine SF, the sensitivity deviation of the distribution of the results of repeated
thresholds are measured again at the end of the test, and measurements of the same threshold.14

RELIABILITY INDICES AVAILABLE ON OCTOPUS PERIMETERS TABLE 7-2

INDEX FORMULA VARIABLES

FALSE POSITIVE (FP) ANSWERS [%] nf+ : Number of false positive answers

ntot+ : Total number of positive catch

trials presented

FALSE NEGATIVE (FN) ANSWERS [%] nf- : Number of false negative answers

ntot- : Total number of negative catch

trials presented

RELIABILITY FACTOR (RF) [%]

SHORT-TERM FLUCTUATION (SF) xi1 : Sensitivity threshold at test location

i determined in 1st of two repeated
measurements

xi2 : Sensitivity threshold at test location

i determined in 2nd of two repeated
measurements

N : Total number of test locations

12 6 Chapter 7 | O verview of visual field representations

REFERENCES
1. Bebie H, Flammer J, Bebie T. The cumulative defect curve: separation of local and diffuse components of visual ield
damage. Graefes Arch Clin Exp Ophthalmol. 1989;227:9-12.
2. Hogan MJ, Alvarado JA, Weddel JE. Histology of the human eye: an atlas and textbook. Philadelphia: WB Saunders; 1971.
3. Mandava S, Zulauf M, Zeyen T, Caprioli J. An evaluation of clusters in the glaucomatous visual ield. Am J Ophthalmol.
1993;116:684-691.
4. Naghizadeh F, Holló G. Detection of early glaucomatous progression with Octopus cluster trend analysis. J Glaucoma.
2014;23:269-275.
5. Gardiner SK, Mansberger SL, Demirel S. Detection of functional change using Cluster Trend Analysis in glaucoma. Invest
Ophthalmol Vis Sci. 2017;58:BIO180-BIO190.
6. Aoki S, Murata H, Fujino Y, et al. Investigating the usefulness of a cluster-based trend analysis to detect visual ield
progression in patients with open-angle glaucoma. Br J Ophthalmol. 2017;doi: 10.1136/bjophthalmol-2016-310069.
7. Holló G. Comparison of structure-function relationship between corresponding retinal nerve ibre layer thickness and
Octopus visual ield cluster defect values determined by normal and tendency-oriented strategies. Br J Ophthalmol.
2017;101:150-154.
8. Naghizadeh F, Garas A, Vargha P, Holló G. Structure-function relationship between the Octopus perimeter cluster mean
sensitivity and sector retinal nerve iber layer thickness measured with the RTVue optical coherence tomography and
scanning laser polarimetry. J Glaucoma. 2014;23:11-18.
9. Holló G. Relationship between OCT angiography temporal peripapillary vessel-density and Octopus perimeter paracentral
cluster mean defect. J Glaucoma. 2017;26:397-402.
10. Holló G. Relationship between optical coherence tomography sector peripapillary angiolow-density and Octopus visual
ield cluster mean defect values. PLoS One. 2017;doi: 10.1371/journal.pone.0171541.
11. Buerki E. Update Octopus Perimetrie 1. Teil: Die Polardarstellung der Gesichtsfelddaten. Ophta. 2006;7:9-12.
12. Holló G, Naghizadeh F. Evaluation of Octopus Polar Trend Analysis for detection of glaucomatous progression. Eur J
Ophthalmol. 2014;24:862-868.
13. Flammer J. The concept of visual ield indices. Graefes Arch Clin Exp Ophthalmol. 1986;224:389-392.
14. Bebie H, Fankhauser F, Spahr J. Static perimetry: accuracy and luctuations. Acta Ophthalmol (Copenh). 1976;54:339-348.
15. Perdicchi A, de Paula A, Sordi E, et al. Cluster analysis of computerized visual ield and optical coherence tomography-
ganglion cell complex defects in high intraocular pressure patients or early stage glaucoma. Eur J Ophthalmol. 2019;doi:1
0.1177/1120672119841774
 127

CHAPTER 8
CLINICAL INTERPRETATION
OF A VISUAL FIELD

INTRODUCTION
Octopus perimeters offer a variety of visual ield repre- a normal and a borderline visual ield, as well as visual
sentations that are based on the raw data (i.e., the sen- ields with localized loss, diffuse loss, and both local and
sitivity thresholds). Each of them focuses on different diffuse loss, and a visual ield with advanced loss. These
clinically relevant aspects of visual ield interpretation, examples provide an excellent starting point to become
to facilitate clinical decision-making. While there is often familiar with the various representations and their be-
overlap in the information provided by the different rep- havior in standard clinical situations and are referenced
resentations, there is typically one representation that is throughout the book. A removable poster of these exam-
best suited to provide information about a certain clinical ples is also included in the back cover of this book.
aspect of a visual ield.
Thereafter, this chapter presents the various representa-
This chapter provides a systematic approach on how to tions in a step-by-step worklow. Because this chapter
interpret visual ields in a clinically meaningful way and focuses on how to interpret visual fields for clinical
highlights particular representations to answer speciic purposes, only an introduction to the deinitions, design
clinical questions. To illustrate how the various repre- and relationships between the representations is present-
sentations can be used in clinical situations, this chapter ed. Detailed information about each representation is
starts by presenting six typical visual ields at different provided in Chapter 7 and should be consulted as required.
stages of disease severity (FIG 8-1). The examples include
12 8 Chapter 8 | Clinic al interpretation of a visual field

EXAMPLES OF SIX TYPICAL VISUAL FIELDS

NORMAL BORDERLINE EARLY TO MODERATE

Diffuse defect

1 Correct patient & examination parameters?

2 Reliable, free of artifacts and trustworthy?

3 Diffuse loss?

Rank Rank Rank

1 59 1 59 1 59

-5 -5 -5

0 0 0
DEFECT CURVE

5% 5% 5%

5 5 5
Defect (dB)

10 95% 10 10 95%
95%

15 15 15

20 20 20

25 25 25
DD

0.1 dB 1.3 dB 6.2 dB

LD

0.2 dB 0.2 dB 0.6 dB

4 Significant local loss?

PROBABILITIES
CORRECTED PROBABILITIES

FIGURE 8-1 A systematic approach to visual field interpretation is recommended and this workflow can be used as a guide
(this figure is also included as a poster in the back cover of this book).
Introduction 129

EARLY TO MODERATE ADVANCED

Local defect Local & diffuse defect

Correct patient & examination parameters? 1

Reliable, free of artifacts and trustworthy? 2
Diffuse loss? 3
Rank Rank Rank
1 59 1 59 1 59

-5 -5 -5

0 0 0

DEFECT CURVE
5% 5% 5%

5 5 5

10 95% 10 95% 10 95%

15 15 15

20 20 20

25 25 25

DD
1.3 dB 5.9 dB 19.3 dB

LD
7.0 dB 6.1 dB 4.7 dB

Significant local loss? 4

PROBABILITIES
CORRECTED PROBABILITIES
13 0 Chapter 8 | Clinic al interpretation of a visual field

EXAMPLES OF SIX TYPICAL VISUAL FIELDS (CONTINUED)

NORMAL BORDERLINE EARLY TO MODERATE

Diffuse defect

5 Assess shape & depth of defect.

GRAYSCALE (COMPARISONS)
CORRECTED GRAYSCALE (CO)

+ + + + 9 9

+ + + + + + + 5 + + + + 5 8 11 10 5 5

+ + + 8 8 10
COMPARISONS

+ + + + + + + 7 + 11 + +
+ + + + + + + + + + + 6 7 7 6
+ + + + + + + + + + + + + 5 7 7 + +
+ + + + + + + + 5 7 7 +
+ + 7
+ + + + + + + + 9 6 6 7
+ + + + + + + + + + + + 8 6 6 6 6 5
+ + + + + + 5 9 5
+ + + + 7 +
+ + + + + + + + 9 15 5 5
+ + + + 10 6

+ + + + + + + + + + 6 + 7 8 8 6 5 5

+ + + + 5 5

+ + + + + +
CORRECTED COMPARISONS

+ + + + + + + + + + + + + + 5 + + +

+ + + 7 + +
+ + + + + + + 5 + 5 + +
+ + + + + + + + + + + + + + +
+ + + + + + + + + + + + + + + + + +
+ + + + + + + + + + + +
+ + +
+ + + + + + + + + + + +
+ + + + + + + + + + + + + + + + + +
+ + + + + + + + +
+ + + + + +
+ + + + + + + + + 8 + +
+ + + + + +

+ + + + + + + + + + + + + + + + + +

+ + + + + +
Introduction 131

EARLY TO MODERATE ADVANCED

Local defect Local & diffuse defect

Assess shape & depth of defect. 5

8 + 19 GRAYSCALE (COMPARISONS)
CORRECTED GRAYSCALE (CO)
8 5 6 6 8 + + 14 22

17 10 17 17
COMPARISONS

15 13 10 + + 6 23 24
26 21 19 23 + + 9 12 12 12 19 26 15 17 27
19 22 22 21 18 + + 14 13 24 25 21 24 9 18
21 15 13 17 10 10 11 12 14 8 9 17
12 5 9
+ 5 6 + + + 5 + 17 22 11 15
+ + + + + + 6 + + 7 5 + 19 10
+ + + 5 5 5 12 19 22 27
+ + + +
+ + + + 7 5 12 5 24
+ + 7 7 22

+ + + + + + 8 9 8 9 10 5 25

+ + 12 + 20

7 + 13
CORRECTED COMPARISONS

6 + 5 + 7 + + 8 16

16 9 11 12
14 11 9 + + + 17 5
25 20 18 21 + + + 7 6 6 + 6 + + 7
17 20 21 20 16 + + 8 7 18 19 15 5 + +
20 14 12 15 + + 5 6 + + + +
10 + +
+ + 5 + + + + + + + + +
+ + + + + + + + + + + + + +
+ + + + + + + 8
+ + + + + +
+ + + + + + 6 + 5
+ + + + +

+ + + + + + + + + + + + 6

+ + 6 + +
13 2 Chapter 8 | Clinic al interpretation of a visual field

EXAMPLES OF SIX TYPICAL VISUAL FIELDS (CONTINUED)

NORMAL BORDERLINE EARLY TO MODERATE

Diffuse defect

6 For glaucoma: Significant cluster defects?

+ 2.5 6.0
CLUSTER ANALYSIS

+ + 8.5

+ + + 3.4 + 5.1
+ + 6.1

+ + 6.6
+ + + + 7.2 6.1

+ + 6.9
+ + 6.4
CORRECTED CLUSTER ANALYSIS

+
+ + +
+
+
+ + 2.3
2.3

+
+ +
+ + 2.1 +
+ +
+
2.0 + +
+

+
+ + +
+
+
+ +
+ + + +
+ +
+

+
+ + +
+
+
+ + +
+

7 For glaucoma: Where to look for structural defects.

POLAR ANALYSIS

S S S
30 20 10 N T T N 10 20 30 30 20 10 N T
[dB] [dB] [dB]
I I I

8 Severity?
MD

-0.2 dB 1.0 dB 6.3 dB

sLV

1.5 dB 1.9 dB 2.5 dB

Introduction 133

EARLY TO MODERATE ADVANCED

Local defect Local & diffuse defect

For glaucoma: Significant cluster defects? 6

17.4 17.1 26.1

CLUSTER ANALYSIS
6.6 19.2 23.7

20.7 + + 17.0 22.5 20.6

15.5 11.1 10.1

3.0 3.2 17.0

+ + 6.4 4.2 25.8 20.3

+ 7.5 24.4
+ 7.8 25.4

CORRECTED CLUSTER ANALYSIS

11.2 6.8
16.1 5.3
13.3 4.4

19.4 +
+ +
+ 11.1 3.2 1.3
14.2 5.2 +

1.7 +
+ +
+
+ +
+ +
+ +
+ 6.5 1.0

+
+ 1.6 5.1
+
+ 1.9 6.1

For glaucoma: Where to look for structural defects. 7

POLAR ANALYSIS

S S S
T N 10 20 30 30 20 10 N T 30 20 10 N T
[dB] [dB] [dB]
I I I

Severity? 8
MD

6.5 dB 10.1 dB 21.7 dB

sLV

8.3 dB 7.2 dB 5.6 dB

134 Chapter 8 | Clinic al interpretation of a visual field

STEP-BY-STEP INTERPRETATION
OF A VISUAL FIELD
OVERVIEW OF STEP-BY-STEP WORKFLOW

VISUAL FIELD INTERPRETATION WORKFLOW

Patient name & age 1

Refraction Correct patient & examination parameters?
Pattern/ strategy

Yes

False positives 2
False negatives Reliable, free of No Retest if clinically
Repetitions artifacts & trustworthy? relevant
Duration

Defect Curve Yes

DD, LD
3
Diffuse loss? Yes Caused by No Potentially unreliable,
pathology? retest if clinically relevant

No Consider pathology
Probabilities Yes Yes leading to diffuse defect
Corrected Probabilities
4
Borderline or significant local loss? No Normal visual field
OR
Diffuse defect only
Yes
Grayscale (Comparisons)
Corrected Grayscale (Comparisons)
Comparisons 5
Corrected Comparisons Assess shape & depth of defect. Consider non-
No glaucomatous field defects
Typical for glaucoma?

Yes

Cluster Analysis 6
Corrected Cluster Analysis Glaucoma only: Consider non-
No glaucomatous field defects
Significant cluster defects?

Yes Consider glaucoma

Polar Analysis 7
Glaucoma only: No Consider non-
Where to look for structural defects. glaucomatous field defects
Is there a relationship?
Yes Consider glaucoma

MD, sLV 8
Severity?

FIGURE 8-2 A systematic approach to visual field interpretation is recommended and this work flow can be used as a guide.
S tep- b y - step interpretation of a visual field 13 5

This chapter provides a systematic step-by-step approach excellent starting point to interpret visual ield results.
on how to interpret visual ields in a clinically meaningful Different sequences may, however, be equally valid or
way and highlights particular representations to answer even more adequate in speciic cases and should be used
speciic clinical questions. This suggested sequence has accordingly. An overview of that worklow is presented
been validated by many experts and can serve as an in FIG 8-2.

STEP 1 – CONFIRM PATIENT AND EXAMINATION PARAMETERS

IMPORTANCE OF CONFIRMING PATIENT AND EXAMINATION PARAMETERS

It is essential to conirm that the correct information is used for each test, in order to make accurate clinical decisions.

STEP 1 – CONFIRM PATIENT AND EXAMINATION PARAMETERS

1 Correct patient & examination parameters?

FIGURE 8-3 Before interpreting visual field results, it is important to confirm that the correct patient data has been entered
and that the correct examination parameters have been used during the test.

Octopus perimeters display key patient and examination • Patient’s name and identiication number
parameters for all visual ields (FIG 8-4). Special attention • Patient’s date of birth and age
should be paid to patient age and refraction. If these are • Tested eye
incorrect, this can lead to non-pathological diffuse visual • Date and time of examination
ield loss. The following parameters are displayed: • Test pattern and strategy
• Stimulus type
• Maximum stimulus intensity and
background luminance
• Refraction entered or trial lens used
• Pupil size
13 6 Chapter 8 | Clinic al interpretation of a visual field

OVERVIEW OF PATIENT AND EXAMINATION PARAMETERS

Demo, John, 1/5/1942 (63yrs) Demo, John, 1/5/1942 (63yrs)

Left eye (OS) / 01/24/2005 / 16:25:23

Seven-in-One
Grayscale (CO) Values [dB]
MD [dB] MS [dB]
16.8 17 17 11.3
12.2 17.6
[%]
19 23 12 14 21 1
0..10

Left eye (OS) / 01/24/2005 / 16:25:23 11..22

23..34
35..46
16
25
15 18
7

22
19

9 15
11
24
25

1
5

47..58 24 28 16 1
30
24 31 30 28
59..70 23 28 28 30 25 21
71..82 18 29 29
27 29
83..94 21 27 26 25
26 28
95..100
18 22 23 23 23 19
6.1 3.9 24.1 25.9
21 24

Comparison [dB] Corrected comparisons [dB] Defect curve

1 Rank 59
9 8 + +

8 + 15 13 5 25 + + 10 8 + 20 -5

22 10 16 5 0
5%
13 11 + 22 8 6 + 17

Defect (dB)
12 22 16 7 7 16 10 + 5
+ 10 21 30 + + 15 24
7 5 17 31 + + 12 26 10 95%
5 +
8 + + + + + + +
6 + 5 + + 6 + + + + + + 15
10 + + 5 + +
5 + + +
8 + + + + + + + 20
5 + + +
25
10 8 7 6 5 7 5 + + + + +

8 + + + Diffuse defect [dB]: 5.4

Probabilities Corrected probabilities

Programs: G Standard White/White / Normal Questions / repetitions: 356 / 23 [%]

P>5

Parameters: 4 / 1000 asb III 100 ms Duration: 15:32 P<5

P<2
P<1
Catch trials: 1/18 (6%) +, 1/18 (6%) - RF: 5.5 P < 0,5

Refraction S/C/A: -3.5 / 1.25 / 35 VA [m]: Programs: G Standard White/White / Normal Questions / repetitions: 356 / 23
MS [dB]:
30°
19.7
4 / 1000 asb III 100 ms 15:32

5.6
Parameters: Duration:
MD [< 2.0 dB]: 9.9
Pupil [mm]: IOP [mmHg]: Catch trials:
Refraction S/C/A:
Pupil [mm]:
1/18 (6%) +, 1/18 (6%) -
-3.5 / 1.25 / 35
5.6
RF:
VA [m]:
IOP [mmHg]:
5.5
sLV [< 2.5 dB]: 8.1

T21 V2.1
NV: T21 V2.1

NV: Comment: Good fixation

OCTOPUS®
EyeSuite™ Static perimetry, V3.5.0
OCTOPUS 101

Comment: Good fixation

FIGURE 8-4 All patient and examination parameters are displayed for every perimetric result.

STEP 2 – DETERMINE WHETHER THE VISUAL FIELD CAN

BE TRUSTED
IMPORTANCE OF ASSESSING WHETHER THE VISUAL FIELD CAN BE TRUSTED

Due to the subjective, patient-related component of reasons can occur frequently, must be identiied and
perimetric testing, unreliable visual field tests, tests should not be clinically interpreted.
with artifacts or tests that cannot be trusted for other

STEP 2 – ASSESS WHETHER THE VISUAL FIELD CAN BE TRUSTED

2 Reliable, free of artifacts & trustworthy?

FIGURE 8-5 Before interpreting visual field results, it is important to confirm that the visual field can be trusted. Visual fields
that are not reliable, contain artifacts or cannot be trusted for other reasons should be retested if this is clinically relevant.

Visual ield results that cannot be trusted may occur for ing of the task to perform, or a desire to inluence the
a number of reasons, as shown in Chapter 3. They can be results. Untrustworthy tests can also occur following set-
caused by inconsistent patient behavior resulting from up errors, for example when incorrect test parameters
fatigue, learning effects, distraction, lack of understand- or inadequate refraction are used, or when the incorrect
S tep- b y - step interpretation of a visual field 13 7

UNTRUSTWORTHY VISUAL FIELD TESTS CAN SHOW SIGNIFICANT DEFECTS

1st test 2nd test 3rd test 4th test 5th test

Reliable normal

Less reliable normal

Normal who experiences difficulties with perimetry

Normal with learning effects (tests 1 to 3)

Normal with artifactual defects (here: lens rim artifact on 1st, 2nd and 4th test)

FIGURE 8-6 The examples above show several visual field series from different individuals with clinically confirmed normal
visual fields and no pathology. Note that while some individuals perform perimetric testing consistently, some show improve-
ment over time due to learning effects, and some perform variably from one examination to the next. This results in untrust-
worthy visual field results, which may be misinterpreted.
13 8 Chapter 8 | Clinic al interpretation of a visual field

date of birth is entered. In addition, artifacts stemming sual ield results of several individuals with clinically con-
from incorrect positioning of the patient, droopy eye- irmed normal visual ields and no pathology.
lid or incorrectly centered correction lenses can also
lead to untrustworthy results. While a well-trained and Since visual ields that cannot be trusted may not repre-
observant visual ield examiner can signiicantly reduce sent the true status of a patient’s visual ield, they may be
the amount of untrustworthy visual ields in a clinical clinically meaningless. It is thus essential to identify them
practice, some patients are simply unable to perform as a irst step in visual ield interpretation. The reliabili-
perimetric testing consistently. ty indicators provided by Octopus perimeters, as well as
further indicators of whether a visual ield can be trusted,
FIG 8-6shows the impact of unreliable visual ield tests, should be used. These are presented in this section.
inconsistent patient behavior and set-up errors on the vi-

FALSE POSITIVE AND FALSE NEGATIVE ANSWERS

Octopus perimeters offer several indicators to detect interpreted with caution and the test should ideally be re-
unreliable visual ields (see TABLE 7-2 for the deinitions peated if it is essential for clinical decision-making. Because
of each of these indicators). The two most important most clinical studies do not accept false positive rates above
indicators of unreliability are the false positive (see FIG 20 to 33%2-7, a false positive answer rate above 33% is
7-22) and false negative answers (see FIG 7-23). marked in red color. This means the visual ield should be
repeated if essential for clinical decision making.
False positive answers occur when the patient presses the
response button when no stimulus is presented. Patients Note that if only a few positive catch trials are presented
who respond in the absence of a stimulus are referred to (e.g., the default setting of the G TOP test contains only six
as trigger-happy, and may have visual ield results that are positive catch trials), one accidentally missed positive catch
better than their true visual ield status, as shown in FIG 8-7. trial has a great impact on the false positive rate. In this situ-
When the false positive answer rate exceeds 15%,1,2 the re- ation, more lenient acceptance criteria may be appropriate.
sults are marked in orange color. This means they should

IMPACT OF FALSE POSITIVE ANSWERS ON VISUAL FIELD RESULT

HIGH FALSE POSITIVES NO FALSE POSITIVES

Real defect is missed Real defect is visible
1st test 2nd test

FIGURE 8-7 The example above shows the impact of a high rate of false positive answers on the visual field. The field on the
left is unreliable because the patient responded in the absence of a stimulus. As a result, the visual field appears better than
the true visual field of the patient, which is shown on the right.
S tep- b y - step interpretation of a visual field 13 9

False negative answers occur when patients do not respond result in false negative rates above 50%, even though the vi-
to stimuli that they should be able to see. Patients who do not sual ield test is performed without any subjective mistakes.8
respond to stimuli they should be able to see may experience False negative answers should thus be interpreted with care
fatigue or a loss of attention, and may have results that are in more advanced vision loss. To provide orientation, a false
worse than their true visual ield status, as shown in FIG 8-8. negative answer rate above 15% is marked in orange color
For most patients, clinical studies often exclude results with and one above 33% is marked in red color.
false negative rates above 20 or 30%.2,5 In patients with se-
vere vision loss, however, false negative errors are not a Note that if only a few negative catch trials are presented,
meaningful indicator of reliability because there is a large in- more lenient acceptance criteria may be appropriate, as ex-
crease in luctuation with increasing visual ield loss. This can plained in the section on false positive answers.

IMPACT OF FALSE NEGATIVE ANSWERS ON VISUAL FIELD RESULT

HIGH FALSE NEGATIVES NO FALSE NEGATIVES

Defect is deeper Real defect shape & depth
1st test 2nd test

FIGURE 8-8 The example above shows the impact of a high rate of false negative answers on the visual field. The field on the
left is unreliable because the patient did not respond to stimuli that should have been seen. As a result, the visual field appears
worse than the true status of the patient’s visual field, which is shown on the right.

CONSISTENCY OF RESULTS WITH FURTHER DIAGNOSTIC TESTS

Any drastic inconsistency in the location of a visual ield defect.9 These visual ield tests can be used in the future
defect in repeated testing can suggest that some of the to evaluate progression or stability.
visual ield tests may not be trusted. This is because
pathologies lead to characteristic visual ield defect Furthermore, if a visual ield defect corresponds to the
patterns in speciic locations. While these defects may results of another diagnostic test, this strongly supports
deepen, expand or in some instances also improve over the decision that the visual ield result can be trusted.
time, they are usually consistently located at the same For example, if a patient shows a visual ield defect
position in repeated visual ield testing. If defect pat- characteristic of glaucoma and shows a related RNFL
terns shift to different locations on repeated testing, as thinning or rim thinning at the related optic disc loca-
can be seen in some of the examples shown in FIG 8-6, tion, as well as high IOP, it will be highly likely that the
this is typically a sign of an untrustworthy visual ield patient has glaucoma and that the visual ield result
test. Therefore it is good clinical practice to base a clin- is thus trustworthy. The results of visual ield tests
ical decision on two to three visual ield tests, in order should therefore always be interpreted in light of the
to conirm or discard an initially observed visual ield full clinical proile.
14 0 Chapter 8 | Clinic al interpretation of a visual field

OTHER INDICATORS TO DETERMINE WHETHER VISUAL FIELD TESTS CAN BE TRUSTED

In addition to the false positive and false negative detect trigger-happy behavior using the Defect Curve.
answers, other indicators are also useful to determine
whether visual ield test results can be trusted. One of Test duration can be a further indicator of whether
the most powerful indicators remains the visual ield visual ield results can be trusted. Abnormally long test
examiner’s direct observation of the patient during the durations can indicate that a patient is struggling with
test. Examiners should note their observations in the pa- the task of performing perimetry.2
tient’s chart.
Finally, if a patient can sustain prolonged testing, one can
In addition, besides the false positive answers, the Defect also retest the determined visual sensitivity thresholds
Curve can also be helpful to identify trigger-happy patient to determine Short-term Fluctuation (SF), a further index
behavior. See FIG 8-10 for more information on how to deined in TABLE 7-2.

STEP 3 – IDENTIFY DIFFUSE VISUAL FIELD DEFECTS

NEED FOR THE DETECTION OF DIFFUSE DEFECTS

It is helpful to be alerted to the presence of diffuse defects cataracts, glaucoma, retinal and neurological diseases),
early in the process of visual ield interpretation, because they may also indicate the presence of untrustworthy
although they are commonly caused by pathology (e.g., visual ield results.

STEP 3 – IDENTIFY DIFFUSE VISUAL FIELD LOSS

3 Diffuse loss?

FIGURE 8-9 Diffuse visual field loss should ideally be identified early on, as it can be a sign of both a pathology leading to
diffuse defects or an untrustworthy visual field.

Diffuse defects are present when most visual ield defect. The etiology of diffuse and local visual ield defects
locations show defects of approximately the same is presented in TABLE 8-1.
magnitude (i.e., there is no apparent visual ield loss
pattern). Conversely, a visual ield with a local defect In clinical decision-making it is essential to clarify the
is characterized by a speciic defect pattern in which cause of diffuse defects. If pathology can be ruled out,
certain visual ield points are affected more than others. the visual ield should be treated as potentially untrust-
Diffuse loss can also occur in the presence of a local worthy and should be retaken, if clinically relevant.
S tep- b y - step interpretation of a visual field 14 1

THE ETIOLOGY OF DIFFUSE AND LOCAL VISUAL FIELD DEFECTS TABLE 8-1

EXAMPLES OF PATHOLOGIES EXAMPLES OF UNTRUSTW ORTHY

RESULTS

DIFFUSE • Lens opacity (e.g., cataract) • Incorrect refraction

( W IDESPREAD) • Cornea opacity (e.g., Fuchs dystrophy) • Incorrect patient age
DEFECT • Dense vitreous opacity • Small pupil size
• Any advanced pathology resulting • Learning effect
in severe visual ield loss • Distraction
(e.g., advanced glaucoma) • Fixation loss
• Fatigue

LOCAL DEFECT • Glaucoma • Lens rim artifact

• Age-related macular degeneration • Lid artifact
• Hemianopia
• Quadrantanopia
• Vitreous opacity

It is important to note that when advanced visual ield loss To quickly identify the presence of diffuse defects, the
is present (e.g., MD > 20 dB), most visual ield locations Defect Curve is useful.
are affected. As a result, diffuse loss is always present.

DEFECT CURVE

The Defect Curve is a graphical representation that pro- representations, and also provides other clinically valu-
vides a summary of the visual ield and distinguishes able information, as shown in FIG 8-10. For more details
between local and diffuse defects.10 In clinical practice of the design and deinitions of the Defect Curve, see
it is very helpful in alerting the clinician to the presence BOX 7A.
of diffuse defects that may be missed by looking at other
14 2 Chapter 8 | Clinic al interpretation of a visual field

DEFECT CURVE – INTERPRETATION AID

NORMAL BORDERLINE DIFFUSE DEFECT

Defect Curve within normal Limited diagnostic value Parallel downward shift of
band Defect Curve
1 Rank 59 1
Rank 59 1 Rank 59

-5 -5 -5

0 0 0
5% 5% 5%

5 5 5
Defect (dB)

10 95% 10 10 95%
95%

15 15 15

20 20 20

25 25 25

LOCAL DEFECT LOCAL & DIFFUSE DEFECT ADVANCED

Drop of Defect Curve Parallel downward shift on Limited diagnostic value
on the right the left and drop on the right
1 Rank 59 1 Rank 59 1 Rank 59

-5 -5 -5

0 0 0
5% 5% 5%
5 5 5
Defect (dB)

10 95% 10 95% 10
95%

15 15 15

20 20 20

25 25 25

TRIGGER-HAPPY HEMISPHERE DEFECTS QUADRANT DEFECTS

Steep rise of Defect Curve Vertical drop of Defect Vertical drop of Defect
on the left Curve in the center Curve towards the right
1 Rank 59 1 Rank 59 1 Rank 59

-5 -5 -5

0 0 0
5% 5% 5%

5 5 5
Defect (dB)

10 95% 10 95% 10 95%

15 15 15

20 20 20

25 25 25

FIGURE 8-10 The Defect Curve alerts the clinician to the presence of diffuse defects and allows a rapid distinction to be
made between local and diffuse defects in early to moderate disease. It furthermore allows the identification of trigger-happy
patients and has a characteristic shape for localized hemisphere and quadrant defects. Note that it is of limited diagnostic
value in borderline (i.e., suspect) situations or in advanced pathology.

The interpretation of the Defect Curve is based on its local defects are present when there is a drop on the
graphical representation and is straightforward. A right-hand side of the Defect Curve (steepening of the
visual ield is normal when the entire Defect Curve lies downward slope), while the left side remains within the
within the normal band (i.e., the 90% conidence inter- normal band. If both local and diffuse defects are present,
val). Diffuse defects are present when there is a parallel there is both a parallel downward shift on the left and a
downward shift of the Defect Curve. Alternatively, only drop on the right.
S tep- b y - step interpretation of a visual field 14 3

The Defect Curve can also identify trigger-happy re- nearly vertical drop at a given location along the curve.
sponse behavior, which results in a steep slope above FIG 8-11 illustrates the usefulness of the Defect Curve in a
the normal band on the left. Hemisphere and quadrant clinical situation.
defects, on the other hand, usually show a characteristic

EXAMPLE OF THE CLINICAL USEFULNESS OF THE DEFECT CURVE

LOCAL DEFECT

DIFFUSE DEFECTS OF VARIOUS MAGNITUDE

st nd
1 test 2 test 3rd test 4th test 5th test
Grayscale (Comparisons)

1 Rank 59 1 Rank 59 1 Rank 59 1 Rank 59 1 Rank 59

-5 -5 -5 -5 -5
Defect Curve

0 0 0 0 0
5% 5% 5% 5% 5%
Defect (dB)

5 5 5 5 5

10 95% 10 95% 10 95% 10 95% 10 95%

15 15 15 15 15

20 20 20 20 20

25 25 25 25 25

FIGURE 8-11 This example shows a series of five visual field tests of a patient with glaucoma with a local superior nasal
defect that deepens from the 1st to the 5th test. In addition, visual fields 2 to 5 show diffuse defects of various magnitudes. The
diffuse defect is most pronounced on the 3rd test, as can be seen from the large parallel downward shift of the Defect Curve.
An inspection of the Defect Curve thus immediately alerts the clinician to the presence of the fluctuating diffuse defect. In
this example, the near-absence of diffuse defect on the 4th and 5th test indicates that the diffuse loss observed on the 3rd test
was due to fluctuation and not pathology.

While the Defect Curve is very helpful and straightfor- cally remain within the normal band. In severe pathology,
ward to interpret in early to moderate disease, it has lim- most visual ield points are affected to some extent and
ited clinical usefulness in suspect situations or advanced absolute defects are not drawn on the Defect Curve. As a
disease. In suspect situations, all visual ield points typi- result, the Defect Curve lies in the lower left-hand corner.

CORRECTING FOR DIFFUSE DEFECTS

Local and diffuse defects may occur together, for exam- which the unspeciic, diffuse defect is removed, as shown
ple in glaucoma patients who also have cataracts. In such in FIG 7-16.
cases, the diffuse defects may mask localized defects. It
is therefore desirable to distinguish between the local The corrected representations provide very helpful
and diffuse visual ield components, in order to analyze clinical information to determine whether there is local
the local visual ield loss independently. To achieve this, loss when diffuse loss is also present, as illustrated in
Octopus perimeters offer corrected representations, in FIG 8-12.
14 4 Chapter 8 | Clinic al interpretation of a visual field

EXAMPLE OF THE CLINICAL USEFULNESS OF THE CORRECTED REPRESENTATIONS

LOCAL DEFECT

DIFFUSE DEFECTS OF VARIOUS MAGNITUDE

st nd
1 test 2 test 3rd test 4th test 5th test
Grayscale (Comparisons)
Probabilities
Corrected Probabilities

FIGURE 8-12 Example of the glaucoma patient with a local superior nasal defect presented in Figure 8-11. Due to the presence
of fluctuating diffuse defects of various magnitudes, the extent of the local defect is difficult to judge. This is the purpose of
the Corrected Probabilities representation, which eliminates the influence of diffuse defect and allows the identification of
local defects.

The corrected representations are very helpful when dif- When there is advanced visual ield loss (e.g., MD > 20 dB),
fuse loss is present or suspected, as can be seen in the correcting the visual ield for diffuse loss does not pro-
borderline, diffuse loss and diffuse and local loss exam- vide clinically useful information, because most visual
ples in FIG 8-1. However, when mainly local defects are ield locations are relatively severely affected. Local
present, the corrected representations are very similar to defects no longer exist in this situation, because the
the uncorrected representations and thus provide only entire visual ield is affected. This can be seen in the
limited additional information, as is visible in the normal advanced example of a constricted glaucoma visual
and local loss examples shown in FIG 8-1. ield in FIG 8-1.
S tep- b y - step interpretation of a visual field 14 5

STEP 4 – DISTINGUISH BETWEEN NORMAL AND

ABNORMAL VISUAL FIELDS
NEED TO DISTINGUISH BETWEEN NORMAL AND ABNORMAL VISUAL FIELDS

Distinguishing between normal and abnormal visual ields smaller than normal luctuation. In sum, the challenge is
is challenging because 1) there is luctuation in healthy to detect faint signals within noise. For example, there are
eyes, 2) this luctuation is not uniformly distributed across borderline ields which may remain stable and normal,
the visual ield, as shown in FIG 2-11, and 3) subtle visu- while others, although appearing the same, have already
al ield defects, as they occur in early glaucoma, are often undergone the irst steps towards pathology.

STEP 4 – DISTINGUISH BETWEEN NORMAL AND ABNORMAL VISUAL FIELDS

4 Borderline or significant local loss?

FIGURE 8-13 Before analyzing a visual field in detail, statistical analysis is used to assess whether a visual field is within nor-
mal limits, or is abnormal. The Probabilities and Corrected Probabilities are used to achieve this essential step, which results
from the normal fluctuation present in perimetry.

In view of the challenges mentioned above, there is a need the direct assessment of the visual ield sensitivity thresh-
for representations that allow for the distinction between olds can be very challenging.
normal and abnormal visual ield locations. This is the
purpose of the Probabilities and Corrected Probabilities It is thus worth looking at these representations prior to
representations, which employ statistical analysis to performing an in-depth analysis of the visual field in
distinguish between normal and abnormal visual ields. order to 1) avoid spending unnecessary time on analysis
These representations are especially useful in borderline of a normal visual ield and 2) avoid confusion between
situations or to detect subtle visual ield change in which normal luctuation and truly abnormal visual ields.

PROBABILITIES AND CORRECTED PROBABILITIES

The Probabilities and Corrected Probabilities repre- given test location. Increasingly darker symbols are used
sentations serve the purpose of distinguishing between to show the decreasing probability that a given visual
normal and abnormal visual ields. They show the prob- ield result would be obtained for a person with an aver-
ability (p) that a person of the same age with an average age normal visual ield (FIG 8-14). For more details on the
normal visual ield (or one with a visual ield corrected deinitions used in the Probabilities representations, see
for diffuse loss in the case of the Corrected Probabilities FIG 7-9, 7-10 and 7-19.
representation) has a certain visual field result at a
14 6 Chapter 8 | Clinic al interpretation of a visual field

PROBABILITIES AND CORRECTED PROBABILITIES – INTERPRETATION AID

PROBABILITIES CORRECTED PROBABILITIES DEFINITION INTERPRETATION

Probability that a person

with a normal visual field
shows this result

p > 5% Likely normal location

p < 5% Potentially abnormal location

p < 2%
p < 1%
p < 0.5% Highly likely abnormal location
Corrected
for diffuse
defect

FIGURE 8-14 The various symbols on the Probabilities representations show the likelihood that a person with a normal visual
field would show a given sensitivity loss. For example, the black square (p < 0.5%) indicates that while it is possible that a per-
son with an average normal visual field could obtain that defect value, the probability of this occurring is very small. Note that
the Corrected Probabilities representation shows the same information, but is adjusted to remove diffuse visual field defects
and is based on the Corrected Comparisons representation.

The clinical interpretation of the Probabilities repre- determine a visual ield as abnormal, these guidelines
sentation is straightforward in that it is easy to see the typically require the presence of one or more clusters of
pattern of visual ield loss marked by dark symbols. abnormal visual ield locations that are consistent with
However, there are some factors to be aware of in clinical the expected visual ield loss pattern of a disease. This
decision-making. Firstly, there are no criteria allowing is because it is highly unlikely that such clusters would
for an unambiguous distinction between normal and form in normal visual ields. If, however, the distribution of
abnormal visual ields. Secondly, it is common to have a a few likely abnormal test locations is random and does
few random test locations that show a p value lower than not correspond with a disease pattern, this can often be
5% in normal visual ields. For further details concerning attributed to normal luctuation. FIG 8-15 illustrates how
these points, see FIG 7-9 and 7-10. to clinically interpret the Probabilities plots of several
visual ields with potential early glaucomatous visual
Due to these factors, the Probabilities representation ield loss, in which the magnitude of visual ield loss, as
must be clinically interpreted with care. Depending on illustrated in the Grayscale of Comparisons representa-
the pathology, different clinical guidelines are available tion, is similar.
to deine visual ield abnormality and severity.11,12 To
S tep- b y - step interpretation of a visual field 14 7

CLINICAL INTERPRETATION OF PROBABILITIES IN BORDERLINE SITUATIONS

GRAYSCALE (Comparisons) PROBABILITIES DESCRIPTION INTERPRETATION

Number of locations at Likely normal

p < 5% 2
p < 2% 2
p < 1% 1

Random distribution of
likely abnormal locations

Number of locations at Likely normal

p < 5% 2

Two adjacent likely abnormal

test locations, no cluster

Number of locations at Likely abnormal

p < 5% 2 Investigate further
p < 2% 1
p < 1% 1
p < 0.5% 2

Five likely abnormal locations

clustered in an inferior partial
arcuate defect pattern
One likely abnormal location
at random position

Number of locations at Likely abnormal

p < 5% 7 Investigate further
p < 2% 3
p < 0.5% 1

Six likely abnormal locations

clustered in a superior partial
arcuate defect pattern
Three likely abnormal locations
clustered in an inferior,
paracentral defect pattern

FIGURE 8-15 The visual field results obtained from four potential early glaucoma cases are presented. They are challenging
to interpret by simply looking at the relative sensitivity loss, which is marked with yellow in the Grayscale of Comparisons rep-
resentation. In the two examples at the top, the few randomly distributed test locations with a probability smaller than 5% also
occur frequently in normal visual fields. The absence of clusters of likely abnormal visual field locations suggests that these
two examples can be interpreted as likely normal. In the two examples at the bottom, the few test locations with a probability
smaller than 5% are organized in clusters and may be interpreted as likely abnormal.
14 8 Chapter 8 | Clinic al interpretation of a visual field

The Probabilities representation is the key graph to look In more advanced disease, however, the Probabilities
at in borderline situations because it is better suited than representation loses diagnostic value because once the
other representations to distinguish between normal disease has progressed to a certain level, most visual
and abnormal visual ields, as illustrated in FIG 8-15. In ield points are highly unlikely to be normal at a signii-
early to moderate disease, it is mainly helpful to detect cance of p < 0.5%. Even though there might still be visual
subtle change, as sensitivity loss is also apparent from ield worsening, it may no longer be apparent from the
the Comparisons representations, as can be seen in the Probabilities representation, as illustrated in FIG 8-16.
examples shown in FIG 8-1. Methods offered to detect and measure progression are
given in Chapter 9.

LIMITATIONS OF THE PROBABILITIES REPRESENTATION IN ADVANCED DISEASE

PROGRESSIVE ADVANCED GLAUCOMA

1st test 2nd test 3rd test 4th test 5th test
Grayscale (Comparisons)
Probabilities

FIGURE 8-16 Example of a series of visual fields from a patient with progressing advanced glaucoma. Even though the visual
field is worsening over time, the change is not apparent in the Probabilities representation because most visual field locations
already show a probability of p < 0.5% in the 1st of the 5 tests.

In case of diffuse loss, the Corrected Probabilities representation should also be consulted to assess abnormal local-
ized loss independently of the diffuse defect, as is shown in FIG 8-12.
S tep- b y - step interpretation of a visual field 14 9

STEP 5 – ASSESS SHAPE AND DEPTH OF DEFECT

NEED FOR ASSESSING SHAPE AND DEPTH OF DEFECT

Once it has been determined that a visual ield is trust- severity of the visual ield defect, and to indicate potential
worthy and abnormal, the shape of the defect area and further diagnostic tests. Typical visual ield defects for
the depth of the defect should be assessed. Since different glaucoma, neuro-ophthalmic and retinal diseases are
pathologies show different disease patterns, these char- presented in FIG 5-1, 5-7 and 5-9.
acteristics are helpful to determine the possible cause and

STEP 5 – ASSESS SHAPE AND DEPTH OF DEFECT

5 Assess shape & depth of defect.

Typical for glaucoma?

FIGURE 8-17 The shape and depth of a defect provide valuable clues to identify and characterize pathology. They can be
analyzed from a graphical (Grayscale of Comparisons and Grayscale of Corrected Comparisons) or numerical (Comparisons
and Corrected Comparisons) map.

GRAYSCALE OF (CORRECTED) COMPARISONS AND (CORRECTED) COMPARISONS

The Comparisons representations are key in that they Four representations are available. The Grayscale of
provide a thorough analysis of both the depth and shape Comparisons and the Grayscale of Corrected Compari-
of defects, thus providing information about the possible sons are color maps of a patient’s visual ield loss. The
causes of the visual ield loss. They do so by comparing Comparisons and Corrected Comparisons represen-
the measured sensitivity thresholds to a normal visual tations show the same information using numerical
ield, as shown in FIG 7-5. maps. An overview of how to clinically interpret them
is provided in FIG 8-18. For further details, see FIG 7-6,
7-7, 7-17 and 7-18.
15 0 Chapter 8 | Clinic al interpretation of a visual field

GRAYSCALE OF COMPARISONS, COMPARISONS AND CORRECTED COMPARISONS – INTERPRETATION AID

GRAYSCALE (Comparisons) CORRECTED GRAYSCALE (CO) DEFINITION INTERPRETATION

Sensitivity loss
[% of normal]
0..10 Normal

11..22
23..34
35..46
47..58 Visual field loss
59..70 (the darker the worse)
71..82
83..94
95..100

COMPARISONS CORRECTED COMPARISONS DEFINITION INTERPRETATION

9 8 + +
8 + 15 13 5 25 + + 10 8 + 20
22 10 16 5
+ Sensitivity loss < 5 dB Normal
13 11 + 22 8 6 + 17
12 2216 7 7 1610 +
+ 10 21 30 + + 15 24 22 Sensitivity loss [dB] Visual field loss
75 17 31 + + 12 26
5 + (the larger the worse)
8+ + + + + + +
6 + 5 + + 6 + + + + + +
10 + 5 + + 5 + + + + Absolute defect Maximum visual field loss
8 + + + + + + + (i.e., Sensitivity threshold 0 dB)
5 + + +
10 8 7 6 5 7 5 + + + + +
8 + + +
Corrected
for diffuse
defect

FIGURE 8-18 The Grayscale of Comparisons and the Grayscale of Corrected Comparisons are color maps that are especially
useful to determine the shape of the sensitivity loss, whereas the Comparisons and Corrected Comparisons representations
are numerical maps showing sensitivity loss in dB. The Grayscale of Corrected Comparisons and the Corrected Comparisons
representations show localized loss only. All representations are key to identifying possible causes of disease.

The Grayscale of Comparisons representation is ideally The Grayscale of Corrected Comparisons shows very
suited to assess defect shapes and to gain a quick irst similar information, but contains a correction factor
impression of a patient’s overall visual ield loss. Since that eliminates diffuse defects. It is useful to assess lo-
it is intuitive to understand, it is also very useful for calized sensitivity loss independently of diffuse loss,
patient education. as explained in FIG 7-16 and FIG 7-18.

Since it is based on the Comparisons representation, However, caution is essential when interpreting the
which eliminates the effect of patient age and eccentric- precise boundaries of the two Grayscale representa-
ity of test locations (see FIG 2-9 for more information), tions, as their high spatial resolution might give the
it represents a patient’s true sensitivity loss, as shown impression that the detailed boundaries of a defect are
in FIG 7-7 and 7-8. known, which is not true, as explained in BOX 8A.
S tep- b y - step interpretation of a visual field 15 1

BOUNDARIES OF GRAYSCALE OF COMPARISONS CAN BE MISLEADING BOX 8A

It is important to remember that in perimetric testing only a discrete number of locations are tested, as
illustrated in FIG 4-4. As a result, there are large gaps between test points for which no information is
available. These gaps are illed with interpolated (i.e., probable or likely) information in the Grayscale of
Comparisons and Grayscale of Corrected Comparisons representations . The boundaries of a visual ield
defect shown in those representations are thus only estimated and may not relect the exact boundaries.
The resolution of a test is only as good as that of the test pattern. This is important to remember when
interpreting the two Grayscale maps, to avoid incorrect interpretation of a slightly changing defect pattern.

GRAYSCALE REPRESENTATIONS ARE INTERPOLATED COLOR MAPS

OCTOPUS GRAPHIC REALISTIC GRAPHIC

Gaps between test points Poor spatial resolution
are interpolated in most perimetric tests

Sensitivity loss
[% of normal]
0..10
11..22
23..34
35..46
47..58
59..70
71..82
83..94
95..100

It is essential to be aware that the Grayscale representations are interpolated visual field maps,
where gaps between visual field points are filled by interpolation (left). Their true spatial resolution
is much poorer, as illustrated in the panel on the right.

Conversely, both the Comparisons and Corrected Com- The Comparisons representations should be looked at
parisons representations are better suited to assess in all clinical situations, as the shape and depth of de-
precise defect depth than the Grayscale representations fect are key information sources in any clinical situation,
because they show visual ield loss in 1 dB steps. Even from early to advanced disease, as shown in the examples
small sensitivity loss can be seen in these representa- in FIG 8-1. An exception may be borderline visual ields in
tions. While the Comparisons representation shows the which defect depth is small and thereby challenging to
actual local visual ield loss (deviation of measured sen- distinguish from normal luctuation. In those situations,
sitivity threshold from normal), the Corrected Compar- the Probabilities representations are better suited to
isons representation shows localized visual ield loss identify the shape and depth of a potential defect.
only, as explained in FIG 7-16 and 7-17.
15 2 Chapter 8 | Clinic al interpretation of a visual field

STEP 6 - ASSESS CLUSTER DEFECTS IN GLAUCOMA

NEED TO ASSESS CLUSTER DEFECTS IN GLAUCOMA

Typical glaucomatous defects (just like other neurolog- the retinal nerve iber bundles in the retina. Thus, in the
ical defects caused by localized retinal nerve iber dam- assessment of glaucomatous visual ield defects, one is
age) consist of a cluster of adjacent defective visual ield looking for a cluster of affected visual ield locations both
locations (FIG 5-1) that correspond to the path followed by in the Probabilities and Comparisons representations.

STEP 6 – ASSESS CLUSTER DEFECTS IN GLAUCOMA

6 Glaucoma only:
Significant cluster defects?

FIGURE 8-19 Assessment of visual field defects in clusters is helpful for the detection of subtle glaucomatous changes. This
is the purpose of the Cluster and Corrected Cluster Analysis.

Many glaucomatous visual ield changes, however, are and speciic to analyze individual test locations to identify
smaller than the normal range of luctuation and are not clusters of visual ield defects.
marked as abnormal. In those cases, the Probabilities rep-
resentation may not be sensitive enough to detect very Therefore, further representations are offered to facilitate
subtle glaucomatous visual ield loss. In addition, it is the interpretation of localized glaucomatous visual ield
time consuming, subjective and not suficiently sensitive loss. The Cluster Analysis and the Corrected Cluster Anal-
ysis were developed for this purpose.

CLUSTER ANALYSIS AND CORRECTED CLUSTER ANALYSIS

The Cluster Analysis and the Corrected Cluster Analysis Similar to the Probabilities representation, they show
have been designed speciically for glaucoma and are the probability (p) that a person with a normal visual
very sensitive to detect subtle glaucomatous visual ield ield (or one with a visual ield corrected for diffuse loss
defects. In Cluster Analysis, visual ield locations corre- in the case of the Corrected Cluster Analysis) would
sponding to the same retinal nerve iber layer (RNFL) have a given Cluster MD. They thus provide clinical in-
bundle are grouped in 10 visual ield clusters and used formation as to whether a visual ield cluster is likely
to calculate the respective average Cluster Mean Defects to be normal or not. This is summarized in FIG 8-20. For
(Cluster MDs). further details of the design and the deinitions of both
Cluster and Corrected Cluster Analysis, see FIG 7-12, 7-13
and 7-20, and BOX 7B.
S tep- b y - step interpretation of a visual field 15 3

CLUSTER ANALYSIS AND CORRECTED CLUSTER ANALYSIS – INTERPRETATION AID

CLUSTER ANALYSIS CORRECTED CLUSTER ANALYSIS DEFINITION INTERPRETATION

Cluster Probability that a

15.8 10.4 MD [dB] person with a
11.3 5.9 normal visual field
shows this result
9.1 24.9 3.7 19.5
9.7 4.3
4.4 + + p > 5% Likely normal cluster
8.3 2.7 2.9 +

2.7 p < 5% Potentially abnormal cluster

5.8 +
3.5 +
8.3 p < 1% Highly likely abnormal cluster

Corrected
for diffuse
defect

FIGURE 8-20 The Cluster Analysis representations group defects into ten clusters according to the paths followed by the
nerve fiber bundles in the retina. Highly likely normal clusters (p > 5%) are marked with a “+” symbol, and likely abnormal
Cluster Mean defects are displayed in normal font (p < 5%) or bold font (p < 1%). The Corrected Cluster Analysis representa-
tion is similar, but eliminates diffuse visual field loss and solely considers local loss.

Clustering visual ield defects according to the paths fol- Probabilities representations.13-15, 21 This is due to the fact
lowed by the nerve fiber bundles in the retina is more that the clustering and averaging procedure signiicantly
sensitive to detect glaucoma and some other optic reduces the inluence of normal luctuation.16 This is
neuropathies than using individual test locations in the further explained in BOX 8B.

CLUSTER ANALYSIS IS HIGHLY SENSITIVE TO DETECT GLAUCOMA BOX 8B

Cluster Analysis has been shown to be more sensitive to detect subtle glaucomatous change13-15, 21 than
looking at individual test locations, due to the reduction of the inluence of normal luctuation. For exam-
ple, in the clinical situation shown in the igure included in this box, most test locations in the supero-na-
sal cluster show a small numerical sensitivity loss (as shown in the adapted Comparisons representation,
which is not available on Octopus perimeters). This sensitivity loss is on average larger than the one in
the infero-nasal cluster. However, when looking at the sensitivity losses at a speciic test location in the
supero-nasal segment, most of these sensitivity losses are too small to manifest as a likely abnormal vi-
sual ield location in the Probabilities representation. As a result, such a visual ield would be considered
as normal, as shown in FIG 8-15.
However, it is highly unlikely that all test locations within the same cluster show such a degree of sensitiv-
ity loss. By averaging the sensitivity losses of all test locations within the cluster, this cluster is very likely
not to be normal at a signiicance of p < 1%. As a consequence, it can be concluded that the visual ield is
likely to be abnormal. Note that the Cluster Analysis uses an idealized graphical display. Consult BOX 7B
for the real boundaries of the Cluster Analysis.
15 4 Chapter 8 | Clinic al interpretation of a visual field

ILLUSTRATION OF THE CLINICAL USEFULNESS OF CLUSTER ANALYSIS

SENSITIVITY LOSS PROBABILITIES CLUSTER ANALYSIS

(Adapted Comparisons representation)

3 1

3 4 2 3 3 5 +
2 1 3.2
2 6 2 0
0 2 2 2 1
+ +
0 0 3 1 3 1 +
0 3 1 2
2
4 1 0 0 +
1 1 1 1 3 1 + +
3 1 1 2 2
2 2 1 0
1 1 +
+
0 3 0 0 2 0

2 4

This example highlights the high sensitivity of Cluster Analysis for the detection of subtle glau-
comatous visual field defects. When looking at the sensitivity loss of the individual test locations
(left) in the superior arcuate cluster (red shading), only one location is marked as abnormal in
the Probabilities representation (center). However, most locations are slightly, but not significantly
elevated, which results in a significantly abnormal (p < 1 %) Cluster MD in the Cluster Analysis.

Besides being more sensitive than the Probabilities rep- potentially abnormal locations to detect clusters of ab-
resentation to detect early glaucomatous visual ield loss normal visual ield locations. This makes the Cluster
(FIG 8-21), the Cluster Analysis is also easier to read and Analysis a fast and useful tool in clinical practice.
avoids having to spend time identifying and counting

ILLUSTRATION OF THE HIGH SENSITIVITY OF CLUSTER ANALYSIS TO DETECT GLAUCOMA

GRAYSCALE (Comparisons) PROBABILITIES CLUSTER ANALYSIS

Two superior paracentral locations at p < 5% Supero-nasal cluster at p < 1%

2.3
+

+ +
+
+
+ +

+
+

FIGURE 8-21 Example of a borderline visual field. By just looking at the Grayscale of Comparisons (left) and Probabilities
(middle) representations, one may interpret this visual field as likely to be normal, as there is no pattern of contiguous ab-
normal locations. However, examination of the Cluster Analysis (right) shows a small, but significant superior arcuate defect
pattern, which calls for further investigation.
S tep- b y - step interpretation of a visual field 15 5

As with the interpretation of the Probabilities represen- Thus, clinicians can be more conident that a cluster at p
tations, some caution is essential in the clinical interpre- < 5 % is truly abnormal when a contiguous cluster is also
tation of the Cluster representation. This is because one abnormal, 14-15 or when there is a spatially corresponding
random cluster showing a p value smaller than 5% is structural defect.
expected to occur frequently, also in normal visual ields.

STEP 7– WHERE TO LOOK FOR STRUCTURAL DEFECTS

NEED TO IDENTIFY RELATIONSHIP BETWEEN FUNCTIONAL AND STRUCTURAL DAMAGE IN GLAUCOMA

When an eye is investigated for glaucoma, both functional ticularly dificult in eyes with early stages of the disease.
alterations and structural damage (neuroretinal rim A mild alteration in the visual ield has more clinical value
tissue loss; decrease of retinal nerve iber layer thickness, for decision-making if a spatially corresponding structur-
RNFLT) should be considered. al alteration is also detected, and vice versa. However, it
is not quite straightforward to understand the geometric
In clinical practice, spatially corresponding structural and relation between the usual presentation of the visual
visual ield alterations are necessary to detect glaucoma ield (perimetry) and the structural results (i.e., fundus
and to separate glaucoma from other diseases. This is par- photography or optical coherence tomography OCT).

STEP 7 – WHERE TO LOOK FOR STRUCTURAL DEFECTS

7 Glaucoma only:
Where to look for structural defects.
Is there a relationship?

FIGURE 8-22 Knowing where to look for structural defects to identify a spatial relationship between structural and functional
results is helpful for the detection of subtle glaucomatous changes. This is the purpose of the Polar Analysis.

Glaucomatous structural damage occurs at the optic disc While there is a correspondence between the structural
and results in a degeneration of the nerve ibers that con- and functional defect locations, the reference coordinates
nect the damaged disc location to the retina. Perimetric are different. Different conventions are therefore used to
testing presents stimuli at various retinal locations along display structural and functional results. See BOX 8C for
the defective layer and is able to identify the defect. more information on the spatial relationship between
structural and functional results.
15 6 Chapter 8 | Clinic al interpretation of a visual field

BOX 8C ANATOMICAL RELATIONSHIP BETWEEN STRUCTURAL AND FUNCTIONAL RESULTS

Glaucomatous structural damage can be observed at the level of the optic disc and results in a degen-
eration of the nerve ibers that connect from the damaged disc location to the retina. As a result, light
entering the retina anywhere along the defective nerve iber bundle cannot be processed and this results
in visual ield defect at the respective retinal location.
Furthermore, while visual ield results are oriented like a real-world image associated with post-process-
ing in the brain, the real world image is lipped both horizontally and vertically when passing through the
lens and entering the retina, and thus the structural and visual ield results are also lipped horizontally
and vertically. This means that a superior visual defect is produced by inferior optic nerve head damage
and a nasal visual ield defect is produced by temporal optic nerve head damage.
In addition, while visual ields are oriented from a patient’s view, structural results are oriented from a
doctor’s view, looking onto a patient’s retina. Due to these different viewpoints, the graphical represen-
tations of structural and functional results appear like mirror images lipped at the horizontal axis, as is
illustrated in the graphic below.

SPATIAL RELATIONSHIP BETWEEN VISUAL FIELDS AND STRUCTURAL RESULTS

VISUAL FIELD ORIENTATION STRUCTURAL ORIENTATION

COMPARISONS RETINA WITH OPTIC DISC

S

9 8

8 + 15 13 5 25

22 10
13 11 + 22
12 22 16 7
+ 10 21 30 270
7 5 17 31
T 5 N N 0 180 T
8 + + +
6 + 5 + + 6
90
10 + 5 + +
8 + + +
5 +

10 8 7 6 5 7
13dB
13d
13
13d
3dB
3dB
8 +

I I
Structural damage and visual field results are flipped across the horizontal midline (i.e., a superior
visual field defect corresponds to an inferior structural defect at the corresponding location at
the optic disc). Note that even though structural and functional results are also flipped across
the vertical midline, the defects are displayed on the same side because of the different viewing
directions of the patient (visual field) and the observing clinician (structure).

Due to the different coordinates used to display structural and functional representations in an intuitive way, to save
and functional results it is useful to have an analysis tool valuable time. This is the purpose of the Polar Analysis.
that facilitates inding the relationship between structural
S tep- b y - step interpretation of a visual field 15 7

POLAR ANALYSIS

The Polar Analysis representation is designed to facili- The Polar Analysis displays individual visual ield defects
tate the identiication of the spatial relationship between as red bars along the perimeter of the optic disc. The lo-
structural and functional results by mapping visual ield cation of the bar indicates the corresponding structural
defects onto the optic disc in the same orientation as a area, and the length of the bar shows the amount of sen-
structural result. This allows intuitive side-by-side sitivity loss in dB, with longer bars indicating greater
comparison between structural and functional results. magnitude of defect, as shown in FIG 8-23. For more infor-
mation on the design of the Polar Analysis, see FIG 7-14.

POLAR ANALYSIS - INTERPRETATION AID

POLAR ANALYSIS DEFINITION INTERPRETATION

Defect [dB] Location of potential structural damage on

• Length of bar indicates defect size [dB] optic disc
• Position along the optic disc represents the entry
angle of RNFL fibers associated to each test location
Short bar Normal location
(Within gray normal range)
S
30 20 10 N T Long bar Abnormal location
[dB] Normal range
I

S Superior
I Inferior
N Nasal
T Temporal

FIGURE 8-23 The Polar Analysis maps functional results onto the optic disc, to appear like a structural result. This assists in
assessing the spatial relationship between visual field defects and possibly associated structural defects.

Clinical use of the Polar Analysis is straightforward. After losses have occurred. Using this graphical representation,
placing it next to a structural result taken during the same the visual ield results can be related to structural results,
time period, a clinician should look for locations in the thereby making detailed and accurate comparison of
Polar Analysis with a cluster of red bars that are outside of damaged segments much easier (see FIG 8-24 for an ex-
normal range. This allows clinicians to see the signiicantly ample). The results of the Polar Analysis have been shown
deviating visual ield test locations that may correspond to correlate well with structural OCT results.17
to structural regions of the optic nerve head rim where
15 8 Chapter 8 | Clinic al interpretation of a visual field

ILLUSTRATION OF THE CLINICAL USEFULNESS OF THE POLAR ANALYSIS

GRAYSCALE (Comparisons) PROBABILITIES CLUSTER ANALYSIS

Two superior paracentral locations at p < 5% Supero-nasal cluster at p < 1%

2.3
+

+ +
+
+
+ +

+
+

STRUCTURAL ORIENTATION
POLAR ANALYSIS FUNDUS IMAGE OCT MACULA MAP
Subtle visual field loss Splinter hemorrhage and subtle RNFL loss Retinal ganglion cell loss
at 7 o’clock position at 7 o’clock position at 7 o’clock position

S
30 20 10 T N
[dB]
I

FIGURE 8-24 Patient with suspected very early glaucoma. While the Probabilities representation is not sensitive enough to
show significant visual field loss, the Cluster Analysis shows that the supero-nasal cluster is likely abnormal at p < 1%. The
Polar Analysis shows a potential defect at the 7 o’clock position of the optic disc, where a very subtle disc hemorrhage is also
found in the fundus photo (darker area within the blue circle). The Macula map picks up the loss of retinal ganglion cells at a
comparable location. Due to the spatial relationship between the subtle defect in the visual field (Polar Analysis) and structur-
al measurements (Fundus Image and Macula Map), glaucoma is confirmed.
S tep- b y - step interpretation of a visual field 15 9

STEP 8 – ASSESS SEVERITY

NEED TO ASSESS SEVERITY OF VISUAL FIELD LOSS

A key element prior to clinical decision-making is to as- It is desirable to have summarizing quantitative measures
sess the severity of visual ield loss in an objective manner, (i.e., global indices) that allow for a characterization of a
in order to decide on an adequate clinical intervention. visual ield in a few words. Summarizing global indices¹⁵
This is challenging to perform from the representations are needed for visual ield severity staging systems, but
discussed so far because there is a wide variety of visual they are also very useful when patients are referred, and
ield defect patterns and depths. they also ind use in clinical studies or guidelines. An
overview of the design and deinitions of available global
indices is provided in TABLE 7-1.

STEP 8 – ASSESS VISUAL FIELD SEVERITY

8 Severity?

FIGURE 8-25 Global indices provide useful information to quickly characterize a visual field and to assess disease severity.

MEAN DEFECT (MD)

The Mean Defect (MD) provides a summary of the over- defects of all test locations, expressed in decibels. Its
all severity of visual ield loss, which is useful to assess calculation formula is shown in TABLE 7-1 and its clinical
overall disease severity and essential to judge disease relevance is illustrated in FIG 8-26.
progression.18 If a visual ield defect worsens, indepen-
dent of whether it is a local or a diffuse defect, MD will The MD is an essential index used in both the Brusini
worsen too. As a general interpretation rule, it can thus and Hodapp-Parrish-Anderson glaucoma staging sys-
be said that the higher the MD, the greater the visual tems.11, 12, 19, 20 In the Hodapp-Parrish-Anderson system,
ield damage. early visual ield defects are characterized by an MD of
up to 6 dB, moderate visual ield defects are character-
As its name suggests, the MD is a mathematical repre- ized by an MD ranging from 6 to 12 dB, and severe visual
sentation of the average of the individual visual ield ield defects have an MD worse than 12 dB.
16 0 Chapter 8 | Clinic al interpretation of a visual field

ILLUSTRATION OF THE USEFULNESS OF MD

NORMAL SUSPECT EARLY TO MODERATE ADVANCED

Diffuse defect Local defect Local & diffuse defect

MD -0.2 dB 1 dB 6.3 dB 6.5 dB 10.1 dB 21.7 dB

FIGURE 8-26 The Mean Defect (MD) summarizes the severity of visual field loss in one number, for comparison with other
patients and to quickly communicate the severity of visual field loss. The examples above show different visual fields with
increasingly severe visual field loss.

SQUARE ROOT OF LOSS VARIANCE (sLV)

In clinical practice, local and diffuse defects typically Clinical interpretation is straightforward. If sLV is small,
have very different causes, as shown in TABLE 8-1, and a visual ield is homogeneous (i.e., all defects have ap-
therefore require different clinical management. How- proximately the same size), suggesting that the visual
ever, the global index MD does not distinguish between ield is normal, or that the deterioration is predom-
them, because it is based on an average visual field inantly diffuse, or that the visual ield has advanced,
defect. For example, two visual ields with similar MD severe visual ield loss. However, if sLV is larger, then
(FIG 8-27) can look completely different, depending on the visual ield is heterogeneous, which means that the
whether there is diffuse or local loss. individual defects vary substantially. The larger the sLV,
the greater the variability among the different defects.
It is thus useful to use an additional global index to It is noteworthy to mention that in early to advanced
distinguish between local and diffuse loss. This is the glaucoma, sLV becomes increasingly higher; but in very
purpose of the square root of Loss Variance (sLV) which advanced glaucoma, sLV is low, since in this stage most
provides a measure of variability of local loss across all visual ield locations are very severely damaged and
test locations. The formula used to calculate it is shown the defect pattern is therefore diffuse.
in TABLE 7-1. Note that sLV is merely the standard deviation
of the local defect values.
S tep- b y - step interpretation of a visual field 16 1

ILLUSTRATION OF THE USEFULNESS OF sLV

DIFFUSE DEFECT LOCAL DEFECT

COMPARISONS COMPARISONS

9 9 8 +

5 8 11 10 5 5 8 5 6 6 8 +

8 10 17 10
+ 11 + + 15 13 10 +
+ 6 7 7 6 26 21 19 23 +
+ 5 7 7 + + 19 22 22 21 18 +
5 7 7 + 21 15 13 17
7 12
9 6 6 7 + 5 6 +
8 6 6 6 6 5 + + + + + +
5 9 7 + 5 + + + + +
9 15 5 5 + + + +
10 6 + +

7 8 8 6 5 5 + + + + + +
5 5 + +

MD 6.3 dB MD 6.5 dB
sLV 2.5 dB sLV 8.5 dB

26
23
22 22
15 21 21 21
19 19
18 sLV
11 11 17 17 8.5 dB
15 15
10 10 10 sLV 13
2.5 dB 12
9 9 9 9 9 11
10 10
8 8 8 8 8
7 7 7 77 7 7 7 7 7 MD 8 8 8 MD
6 6 6 6 66 6 66 6 6 6.3 dB 6 6 6 6.5 dB
5 5 5 5 5 55 5 5 5 55 5 5 5
+ + + + + + ++ + ++ +
+ + ++
+ ++ + + ++ + +
+ + +++ +++ +

FIGURE 8-27 Visual fields with either diffuse defects (left) or local defects (right) appear fundamentally different, but can
have similar MD values, as this example illustrates. The square root of Loss Variance (sLV) is then useful to distinguish
between the two situations, as sLV is smaller in the case of homogeneous or diffuse visual field defects and larger in the case
of heterogeneous or local visual field defects. In short, sLV is a measure of how much the defects at different test locations
differ from the mean defect, as illustrated in the graphic at the bottom.
16 2 Chapter 8 | Clinic al interpretation of a visual field

sLV is an essential index used in the Brusini Glaucoma used to judge local disease progression in glaucoma. For
Staging System12, 19, 20 in combination with MD to divide more information on how to judge disease progression,
visual field loss into 5 stages, and is also commonly see Chapter 9.
References 163

REFERENCES
1. Lee M, Zulauf M, Caprioli J. The inluence of patient reliability on visual ield outcome. Am J Ophthalmol. 1994;
117:756-761.
2. Yohannan J, Wang J, Brown J, et al. Evidence-based criteria for assessment of visual ield reliability. Ophthalmology.
2017;124:1612-1620
3. Advanced Glaucoma Intervention Study. 2. Visual ield test scoring and reliability. Ophthalmology. 1994;101:1445-1455.
4. Gillespie BW, Musch DC, Guire KE, et al. The collaborative initial glaucoma treatment study: baseline visual ield and
test-retest variability. Invest Ophthalmol Vis Sci. 2003;44:2613-2620.
5. Johnson CA, Keltner JL, Cello KE, et al. Baseline visual ield characteristics in the ocular hypertension treatment study.
Ophthalmology. 2002;109:432-437.
6. Keltner JL, Johnson CA, Cello KE, Wall M, NORDIC Idiopathic Intracranial Hypertension Study Group. Baseline visual ield
indings in the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT). Invest Ophthalmol Vis Sci. 2014;55:
3200-3207.
7. Miglior S, Zeyen T, Pfeiffer N, et al. The European glaucoma prevention study design and baseline description of the
participants. Ophthalmology. 2002;109:1612-1621.
8. Bengtsson B, Heijl A. False-negative responses in glaucoma perimetry: indicators of patient performance or test
reliability? Invest Ophthalmol Vis Sci. 2000;41:2201-2204.
9. European Glaucoma Society. Terminology and Guidelines for Glaucoma. 4th ed. Savona: PubliComm; 2014.
10. Bebie H, Flammer J, Bebie T. The cumulative defect curve: separation of local and diffuse components of visual ield
damage. Graefe's Arch Clin Exp Ophthalmol. 1989;227:9-12.
11. Hodapp E, Parrish RK, Anderson DR. Clinical decisions in glaucoma. 1st ed. St. Louis: Mosby; 1993.
12. Susanna R Jr., Vessani RM. Staging glaucoma patient: why and how? Open Ophthalmol J. 2009;3:59-64.
13. Naghizadeh F, Holló G. Detection of early glaucomatous progression with Octopus cluster trend analysis. J Glaucoma.
2014;23:269-275.
14. Gardiner SK, Mansberger SL, Demirel S. Detection of functional change using Cluster Trend Analysis in glaucoma. Invest
Ophthalmol Vis Sci. 2017;58:BIO180-BIO190.
15. Aoki S, Murata H, Fujino Y, et al. Investigating the usefulness of a cluster-based trend analysis to detect visual ield
progression in patients with open-angle glaucoma. Br J Ophthalmol. 2017;doi: 10.1136/bjophthalmol-2016-310069.
16. Mandava S, Zulauf M, Zeyen T, Caprioli J. An evaluation of clusters in the glaucomatous visual ield. Am J Ophthalmol.
1993;116:684-691.
17. Holló G, Naghizadeh F. Evaluation of Octopus Polar Trend Analysis for detection of glaucomatous progression. Eur J
Ophthalmol. 2014;24:862-868.
18. Flammer J. The concept of visual ield indices. Graefe's Arch Clin Exp Ophthalmol. 1986;224:389-392.
19. Koçak I, Zulauf M, Hendrickson P, Stümpig D. Evaluation of the Brusini glaucoma staging system for follow-up in
glaucoma. Eur J Ophthalmol. 1997;7:345-350.
20. Koçak I, Zulauf M, Bergamin O. Evaluation of the Brusini glaucoma staging system for typing and staging of perimetric
results. Ophthalmologica. 1998;212:221-227.
21. Perdicchi A, de Paula A, Sordi E, et al. Cluster analysis of computerized visual ield and optical coherence tomography-
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0.1177/1120672119841774
 165

CHAPTER 9
INTERPRETATION OF VISUAL
FIELD PROGRESSION

INTRODUCTION
Vision-related quality of life is severely diminished both Because progression in diseases such as glaucoma is
when diffuse deterioration within the central 30-degrees typically slow, the magnitude of luctuation can be larger
of the visual ield (increase of MD) reaches a critical than the annual rate of progression. Identifying disease
level and when localized progression prevents the per- progression from a series of visual ields is therefore a
formance of normal daily activities (e.g., due to severe challenging and time-consuming task in clinical prac-
progression of a localized inferior paracentral scotoma). tice (FIG 9-1). As a result, expert agreement is moderate
In clinical practice, it is essential to detect progression at best (45% to 65%).¹-⁵ Statistical progression analy-
and to measure its speed (i.e., rate of progression ses greatly support the assessment of progression that
expressed as change per year in dB) as early as possible is needed for clinical decision-making. The use of pro-
to make decisions about potential interventions before gression software options was shown to improve expert
signiicant visual ield loss develops. agreement,¹-⁵ but to also reduce overall visual field
analysis time.⁴
16 6 Chapter 9 | I nterpretation of visual field progression

CHALLENGES ASSOCIATED WITH ASSESSING VISUAL FIELD PROGRESSION

Stable?
st nd rd th th th
1 test 2 test 3 test 4 test 5 test 6 test
Or progressing?
Glaucoma Patient 1

Glaucoma Patient 2

Glaucoma Patient 3

FIGURE 9-1 Determination of whether visual fields are stable over time or whether they are progressing can be challenging,
especially when the change is small and there is considerable fluctuation. This is illustrated with the visual field series of three
different patients.

The EyeSuite Progression Analysis function of the Octo- The Cluster Trend Analysis and Polar Trend Analysis
pus perimeters has been designed to assess visual ield have been speciically designed to detect subtle glau-
progression in an effective and eficient way. It includes comatous change. The Cluster Trend Analysis assesses
the following three types of progression analysis: Global cluster-specific progression within ten nerve fiber
Trend Analysis (GTA), (Corrected) Cluster Trend Analy- bundle regions separately, which is particularly useful
sis (CTA and CCTA), and Polar Trend Analysis (PTA) in glaucoma in which localized (cluster) progression
are shown in FIG 9-2. and stability occur at different locations independently
from each other in the same eye. Furthermore, the Polar
The Global Progression Analysis measures and statisti- Trend Analysis facilitates the detection of spatially cor-
cally classiies long-term change in the global indices, responding structural and visual ield changes.
namely Mean Defect (MD), Diffuse Defect (DD), Local
Defect (LD) and square Root of Loss Variance (sLV). The different types of progression analyses make a
It not only assesses whether a series of visual ields is statement about whether a visual ield series is stable
stable or shows significant change, but also provides or not and also show the location of progression. How-
information about the rate of change in dB/year and on ever, it is also important to know the shape, location and
the local, diffuse or combined nature of progression. depth of a defect. For example, a deep defect approaching
Introduction 167

the fovea solicits a much more aggressive treatment tations of all visual ield tests are also displayed as a
than a shallow defect in the periphery. To provide this default and may be changed to any other single ield
information, the Grayscale of Comparisons represen- representation such as the Cluster Analysis.

PROGRESSION ANALYSIS TOOLS AVAILABLE IN OCTOPUS PERIMETERS

EYESUITE PROGRESSION ANALYSIS

GLOBAL TREND ANALYSIS (CORRECTED) CLUSTER TREND ANALYSIS

MD sLV Cluster MD progression? Corrected Cluster MD

Stable or overall Increasing/decreasing progression?
progression? inhomogeneity?
0

0 4.1 3.5
2.1 1.5

-0.8 6.7 -1.4 6.0

2.6 2.0
0.4 -0.2
1.0 0.4 -0.3 -0.2

15
0.7 0.0
0.6 -0.1

25 15
2000 2001 2002 2003 2004 2005 2000 2001 2002 2003 2004 2005

Slope: 1.9 dB / Yr (p < 0.5%) Slope: 2.1 dB / Yr (p < 0.5%)

POLAR TREND ANALYSIS
DD LD
Diffuse progression? Local progression? Where to look for
0 structural progression?
0

S
30 20 10 N T
[dB]
I

25 15
2000 2001 2002 2003 2004 2005 2000 2001 2002 2003 2004 2005

Slope: 0.6 dB / Yr Slope: 1.8 dB / Yr (p < 0.5%)

SERIES OF VISUAL FIELDS

Defect location & depth?

FIGURE 9-2 Octopus perimeters offer 3 types of progression analysis to assess visual field change over time. A Global Trend
Analysis based on the four global indices MD, sLV, DD and LD, and, for glaucoma, both Cluster (and Corrected Cluster) Trend
Analysis and Polar Trend Analysis. In contrast to simply looking at a series of visual fields, most of these analyses employ
statistical methods to determine progression. To provide orientation about both defect location, shape and defect depth, the
series of Grayscale representations is also provided.
16 8 Chapter 9 | I nterpretation of visual field progression

ASSESSMENT OF GLOBAL
VISUAL FIELD CHANGE
CHANGE OF MEAN DEFECT (MD) AS A MEASURE OF
GLOBAL CHANGE
To judge whether a current treatment strategy is effec- the area of the visual ield that was tested. It is the aver-
tive as well as to make a clinical decision about future age of all individual sensitivity losses and is expressed in
interventions, it is essential to know whether, overall, a dB. Consequently, if any visual ield location worsens or
visual ield series is stable, worsening or improving. This improves, MD will also change accordingly, even though
can be achieved by analyzing the change of the global in- the change may be small. This makes MD a good index to
dex Mean Defect (MD) over time. track overall visual ield change. For more information on
the deinition of the index MD see TABLE 7-1, and for more
The global index MD summarizes the sensitivity loss over information on its clinical interpretation see FIG 8-26.

TREND ANALYSIS FOR THE VISUALIZATION OF CHANGE

The simplest way to assess MD change is to plot the MD If there is no luctuation and the change in MD over time
of each visual ield test in a two-dimensional graph. The is suficiently large, it is simple to graphically determine
MD is plotted on the Y-axis and test date is plotted on the whether a series of visual ields is stable, worsening or
X-axis. This allows graphical assessment of visual ield improving by drawing a trend line. Intuitively, the trend
change over time as shown in FIG 9-3. Because an in- line corresponds to the line that provides the best linear
creasing MD represents visual ield worsening, it is most it for all the MD points. If this line is lat, then the visual
intuitive to use a scale showing the smallest MD at the ield series is stable, if it is sloping upwards, then the
top and the largest at the bottom. series is improving and if it is sloping downwards, then
the series is worsening (FIG 9-4).
A ssessm ent of glob al visual field c hange 16 9

TREND ANALYSIS FOR DISPLAYING OVERALL CHANGE

MD [dB] 0.9 2.2 1.7 4.5 3.3 6.0

Test date 10/2002 01/2003 06/2003 12/2003 06/2004 01/2005

10
MD [dB]

15

20

25
2002 2003 2004 2005
Test date [years]

FIGURE 9-3 A simple way to assess visual field change over time is to draw a two-dimensional graph with the test date of
each visual field test on the X-axis and the corresponding MD on the Y-axis. By drawing a trend line that provides the best
linear fit for the individual MD points (red line), it is easy to see that this visual field series is worsening (downward slope).

GRAPHICAL INTERPRETATION OF A TREND LINE

STABLE WORSENING IMPROVING

0 0 0

5 5 5
MD [dB]

MD [dB]

MD [dB]

10 10 10

15 15 15

20 20 20

25 25 25
2002 2003 2004 2005 2002 2003 2004 2005 2002 2003 2004 2005

FIGURE 9-4 If visual field change is sufficiently large, just looking at the red trend line allows one to intuitively assess whether
a visual field series is stable (flat line, left) worsening (downward sloping line, middle) or improving (upward sloping line, right)
over time.
17 0 Chapter 9 | I nterpretation of visual field progression

This approach is referred to as trend analysis and is used The steepness of the line is referred to as the slope and
for all representations that are part of the EyeSuite Pro- is used to assess the rate of change in MD over time. The
gression Analysis. To best it the trend line to the mea- rate of change is expressed in dB per year and is derived
sured MD values, linear regression analysis with the by determining the amount of change in MD (Y-axis) that
ordinary least squares it is used. For more details on this occurs over the selected period of time (X-axis). In FIG
approach as well as key characteristics of trend analysis, 9-5, the rate of change for MD is 1.9 dB/year.
refer to BOX 9A.

SLOPE OF TREND ANALYSIS PROVIDES RATE OF CHANGE

Slope
1.9 dB/year
5
1.9 dB

10
MD [dB]

15

20 1 year

25
2002 2003 2004 2005
Test date [years]

FIGURE 9-5 To determine the rate of overall visual field change, the best-fit line is drawn through the MD data points in the
Global Trend Analysis. Once this trend line is drawn, the actual data points can be discounted and the rate of change can be
determined using the slope of the trend line. The rate of change is automatically expressed in dB per year. In this example, the
slope or rate of change is 1.9 dB/ year.
A ssessm ent of glob al visual field c hange 17 1

USING PROBABILITIES TO DISTINGUISH BETWEEN STABLE

AND CHANGING VISUAL FIELD SERIES
A key challenge in the assessment of visual ield progres- Worsening at p < 5%: this visual ield series shows
sion is the distinction between a series of visual ields overall worsening. There is a smaller than 5% (and larg-
that is truly changing and one that is stable but shows er than 1%) chance that a stable visual ield series would
luctuation. This challenge is greater in cases in which look like the series in question, which means there is a
the magnitude of the change is small and the amount of high likelihood that the visual ield series is worsening.
luctuation is large, which is a common situation when
assessing glaucomatous progression. Worsening at p < 1%: this visual ield series shows
overall worsening. There is a smaller than 1% chance
In clinical practice, the trend line alone is not suficient that a stable visual ield series would look like the series
to distinguish between stable and changing visual ields. in question, which means there is very high likelihood
This is because most visual ield series will show at least that the visual ield series is worsening.
a small trend upwards or downwards. The challenge is
to determine whether this trend is signiicantly different Improvement at p < 5%: this visual ield series shows
from a lat line (i.e., one with a slope of zero). overall improvement. There is a smaller than 5% (and
larger than 1%) chance that a stable visual ield series
To distinguish between a stable and a truly changing se- would look like the series in question, which means there
ries of visual ields, a t-test is used. The t-test is a statis- is a high chance that the visual ield series is improving.
tical test of hypothesis that allows the determination of
whether two sets of data are signiicantly different from Improvement at p < 1%: this visual ield series shows
each other. For trend analysis, the t-test is applied to the overall improvement. There is a smaller than 1% chance
observed slope to determine whether it is signiicantly that a stable visual ield series would look like the series
different from a slope of zero (e.g., lat line showing no in question, which means there is a very high chance that
change over time, which represents the typical situation the visual ield series is improving.
of a stable visual ield series). The concept of probability
is then used to determine the probability (p) that a stable Floor effect: There is more than 20 dB sensitivity loss
visual ield series with an assumed slope of zero would in the visual ield series and no signiicant change, which
show a given slope (see BOX 9A). Its interpretation is means that the determination of progression or stability
similar to the p values used in the Probabilities plot (see is not possible due to the advancement of the disease.
FIG 7-9 and 7-10). If there is a low probability that a stable
visual ield series would look like the series in question, If there is no symbol, then there is a probability of p > 5%
then that series is unlikely to be stable and consequently that a stable visual ield series would look like the series
it is likely that the visual ield series is changing. in question or in other words that the data do not show
change at the levels mentioned above. This either means
To facilitate interpretation, the EyeSuite Progression that the visual ield is stable, or that the data available
Analysis uses red downward arrows to show signiicant are not suficient to capture change. This is often the case
worsening and green upward arrows to show signiicant when only a few visual ield tests are available and pro-
improvement at two probability levels and also marks gression is slow or when luctuation is large as explained
loor effects using the following symbols: in BOX 9A.
17 2 Chapter 9 | I nterpretation of visual field progression

BOX 9A GENERAL CHARACTERISTICS OF TREND ANALYSIS

LINEAR REGRESSION ANALYSIS WITH ORDINARY LEAST SQUARES ESTIMATES TO

DETERMINE THE TREND LINE
To determine the trend line, EyeSuite Progression Analysis uses linear regression analysis with least
squares estimates. Linear regression analysis is a statistical approach for modeling the relationship
between two variables using a straight line. An excellent it for the trend line is obtained using the least
squares method, which is a commonly used approach to it the regression line. The best it of the trend
line is achieved by minimizing the sums of squared residuals (i.e., the vertical distance between each
data point and the itted regression line).

OCTOPUS PERIMETERS USE LEAST SQUARES LINEAR REGRESSION TO BEST FIT A TREND LINE

10
MD [dB]

15
Residuals – Distance between MD data and trend line
Best fitted trend line
20

25
2002 2003 2004 2005
Test date [years]

The least squares linear regression approach determines a best itted trend line by minimizing the vertical
distance between the individual test points and the trend line. This vertical distance is called the residual
and is depicted by the red lines in this example. If the it were perfect, all individual test points (gray dots)
would fall exactly on the trend line (gray line).

SIGNIFICANCE IS INFLUENCED BY THE AMOUNT OF FLUCTUATION

The trend line describes the data and allows for the determination of the slope. However, this is not
suficient to distinguish between a stable and changing visual ield series because there is typically at
least some positive or negative slope (even if it is very small) due to the luctuation of the variable (e.g.,
MD) over time.
Therefore, it is necessary to determine whether the observed slope corresponds to a true change, or
whether it may be explained by luctuations in the data. The t-test is used to determine whether the
observed slope is signiicantly different from zero (as would be expected if the series of visual ields
was stable) using two levels of signiicance (p < 5% and p < 1%).
The amount of luctuation is taken into account by the t-test. This is necessary because the same slope
may indicate a signiicant trend when the luctuations are small, but may not be signiicant when luctu-
ations are large. In other words, a larger slope is needed to detect true change for the same number of
tests and the same follow-up length when large luctuations are present.
A ssessm ent of glob al visual field c hange 17 3

ILLUSTRATION OF THE INFLUENCE OF FLUCTUATION ON SIGNIFICANCE

TREND ANALYSIS DESCRIPTION INTERPRETATION

MD Mean defect No symbol indicating change NO PROGRESSION

0
Slope Slope 0.9 dB/year Large slope
0.9 dB/year
Outliers in 3rd & 4th test Considerable fluctuation

15 Stable series
Outliers

Considerable fluctuation
25 may prevent a change to
2010 2011 2012
be declared significant

MD Mean defect Significant worsening at p < 5% WORSENING

0
Slope 0.6 dB/year Smaller slope

Test data close to trend line Consistent results

Slope
15 0.6 dB/year Progressing series

25
2010 2011 2012

In this igure, the visual ield series from two different patients are shown over a comparable time period
with approximately the same amount of test data. In the example on top, luctuation is large because the 3rd
and 4th test are outliers. As a result, even the relatively large slope (0.9 dB/year) is insuficient to indicate
signiicant change and the series appears to be stable (no symbol). More visual ield tests may be needed to
identify whether the series is truly stable or progressing. However, when there is less luctuation in the visu-
al ield data (bottom), even a small slope (0.6 dB/year) sufices to detect signiicant change (red downward
arrow) and the series is conirmed as progressing.

SIGNIFICANCE IS INFLUENCED BY THE NUMBER OF VISUAL FIELD TESTS

The number of visual ield examinations (n) included in a trend analysis is important because it inlu-
ences the outcome of the t-test. The EyeSuite Progression Analysis can be performed with a minimum
of three visual ield tests. However, if there are only three or four visual ield tests included in the anal-
ysis, the slope must be quite steep to be able to separate true change from luctuations. On the other
hand, if there are many visual ield tests included, even a visual ield series with a shallow slope can
identify signiicant change. For typical progressing visual ields, trends will not become signiicant be-
fore ive or six examinations are included in the analysis. Guidelines on glaucoma treatment⁶ typically
recommend a minimum of six visual ields in the irst two years to reliably detect glaucomatous visual
ield progression. However, if luctuation is large and the slope is small, an even larger number of visual
ield tests are required to detect progression.⁷,⁸
17 4 Chapter 9 | I nterpretation of visual field progression

THE INFLUENCE OF THE NUMBER OF VISUAL FIELD TESTS ON SIGNIFICANCE

TREND ANALYSIS DESCRIPTION INTERPRETATION

MD Mean defect No symbol indicating change NO PROGRESSION

0
Slope 0.9 dB/year Large slope
6 Tests
Outliers in 3rd & 4th test Considerable fluctuation

15 Outliers 6 Visual field tests Series declared stable

because of fluctuation
Slope 0.9 dB/year
25 More test data is needed
2010 2011 2012 2013 2014

MD Mean defect Significant worsening at p < 1% WORSENING

0
Slope 0.7 dB/year
10 Tests
Test data close to trend line Overall consistent results

15 10 Visual field tests Progressing series

Sufficient number of tests
Slope 0.7 dB/year
25
2010 2011 2012 2013 2014

SERIES OF VISUAL FIELDS

Defect location & depth?

Tests 1-6
All tests

The number of visual ield tests signiicantly inluences whether a visual ield series is considered stable or
not. More visual ields are required when the slope is shallow or when luctuation is large. In this example,
due to luctuation in tests 3 and 4, the visual ield series doesn’t show signiicant change after the initial
6 tests (top) even though the slope of 0.9 dB/year is relatively large. Change is only detected by the trend
analysis upon inclusion of more tests (bottom).

MD TREND ANALYSIS
Interpretation of MD Trend Analysis in clinical practice is improving can be made solely by looking at the red down-
a fast and straightforward process (if adequate visual ields ward (signiicant worsening) or the green upward (sig-
are selected, which is described in more detail later in niicant improvement) arrows displayed. To assess rate
this chapter). The decision about whether a visual ield of change, the slope is numerically displayed as change in
series is stable, signiicantly worsening or signiicantly dB/year at the bottom of the graph (FIG 9-6).
A ssessm ent of glob al visual field c hange 17 5

MD TREND ANALYSIS – INTERPRETATION AID

MD TREND DEFINITION INTERPRETATION

Probability of stable visual field series

Y-axis
showing this result
MD [dB]
Magnitude of
visual field loss No symbol p > 5% Stable

W orsening at p < 5% Likely worsening

0
W orsening at p < 1% Highly likely worsening

Improvement at p < 5% Likely improving

15 Improvement at p < 1% Highly likely improving

Floor effect (MD > 20 dB, Maximum loss

Slope: 1.9 dB/year no significant progression) (No further measurement of progression possible)
25
2000 2001 2002 2003 2004 2005
MD trend line
X-axis
Time (years) 1.9 dB/year Slope [ dB/ year] MD change in dB/year

MD of visual field test

(taken at specific date)

Normal range of MD

15 MD of 15 dB Seriously impaired visual field

FIGURE 9-6 MD Trend Analysis allows for a q uick identification of worsening (red downward arrow) or improvement (green
upward arrow) of a visual field series. In addition, it displays the rate of change (slope in dB/ year) and shows the trend graphic
including slope and individual test points to graphically assess severity of visual field loss, rate of progression, test interval,
amount of fluctuation and number of tests included in the analysis.

While the detailed graphical presentation of the trend line Visual ields included in the analysis are marked in a
and the test data is not necessary for deciding about the different color which supports the visual ield selection
presence and rate of MD change, it provides valuable infor- process. Lastly, different symbols are used for each pe-
mation. It allows for a quick assessment of disease severity rimeter model to draw attention to a possible perimeter
as well as rate of disease progression. The lower the level model-related bias. This can for example occur when a
of the curve, the more the disease has progressed and patient is tested for the irst time on a new perimeter
the steeper the curve, the more rapid the change. model and shows a strong learning effect. For more
information on transitioning from one perimeter model
The graph also allows for a quick determination of the to another, please refer to Chapter 12.
frequency of the visual ield tests performed. In addition,
it allows one to see at a glance if there is a signiicant out- Further orientation is provided by a gray band at the top
lier, which calls for more careful evaluation to make sure which indicates the normal range of MD (i.e., the 95%
that this visual ield is reliable and whether it should be conidence interval) and a red line at 15 dB which rep-
included in the analysis. For more information, consult resents seriously impaired visual ields. The graph stops
the next section in this chapter on adequate selection of at 25 dB because in many countries, an MD of 20 to 25 dB
visual ield tests. is considered legal blindness.
17 6 Chapter 9 | I nterpretation of visual field progression

INTERPRETATION OF MD TREND ANALYSIS

MD Trend Analysis provides information about the pres- at the end of their respective lifespan, the 80-year-old pa-
ence and rate of progression as well as the magnitude of tient would have an MD of 7 dB whereas the 50-year-old
the sensitivity loss (i.e., magnitude of MD) of a patient. patient would have an MD of 19 dB. However, if this same
However, this data is not suficient to make a clinical 80-year-old patient showed a progression rate of 2 dB
decision as these factors have a very different meaning per year, at age 90 this patient would have an MD of 23
depending on their relation to each other as well as the dB, which represents near total visual ield loss.
patient’s age and life expectancy.
It therefore goes without saying that these factors as well
For example, an MD of 3 dB in a patient progressing at as a patient’s lifestyle, adherence to and persistence with
a rate of 0.4 dB/year has a very different meaning in a medications, other clinical issues and the practitioner’s
50-year-old patient compared to an 80-year-old patient. overall clinical assessment have to be taken into account
Assuming a life expectancy of 90 years for both patients to make a clinical decision.
and projecting the current slope linearly into the future,

SELECTION OF ADEQUATE VISUAL FIELDS FOR ANALYSIS

IMPORTANCE OF SELECTING ADEQUATE VISUAL FIELD TESTS FOR ANALYSIS

A trend analysis is only clinically meaningful if adequate included in the progression analysis should be reliable,
visual ields are selected for analysis. To facilitate the be part of a relevant time period, and be tested using
selection process, the EyeSuite Progression Analysis the same test parameters. Each of these requirements is
allows examiners to choose the visual ields to be in- described in this section.
cluded in the analysis with a simple click. Visual ields

EXCLUSION OF UNTRUSTWORTHY VISUAL FIELD TESTS

It is important that only trustworthy visual ields, re- luctuation in a visual ield series and may change the
liable and free of artifacts, be included in the analysis. outcome of visual field trend analysis as illustrated
Untrustworthy visual fields increase the amount of in FIG 9-7.
A ssessm ent of glob al visual field c hange 17 7

IMPORTANCE OF EXCLUSION OF UNTRUSTWORTHY VISUAL FIELD TESTS

TREND ANALYSIS DESCRIPTION INTERPRETATION

MD Mean defect High false Filled green upward arrow IMPROVING

positives
(Improvement at p < 1% )
0
Slope – 0.6 dB/ year

Unreliable visual fields included Considerable fluctuation

15
Artifact

Slope -0.6 dB/year

25
2010 2011 2012 2013 2014

MD Mean defect High false No symbol STABLE

positives
0 Slope 0.0 dB/ year

1st test with ptosis artifact excluded Considerable fluctuation

15
Artifact

Slope 0.0 dB/year

25
2010 2011 2012 2013 2014

MD Mean defect High false Filled red downward arrow WORSENING

positives
(W orsening at p < 1% )
0
Slope 0.9 dB/ year

1st test with ptosis artifact and Consistent results

5th & 6 th test with high false positive
15 rates excluded
Artifact

Slope 0.9 dB/year

25
2010 2011 2012 2013 2014

SERIES OF VISUAL FIELDS

Defect location & depth?

False False
Ptosis positives: positives:
71% 57%

FIGURE 9-7 Visual field tests that are not trustworthy can significantly alter the trend analysis result as the example above
illustrates. In this example, the first test is not trustworthy due to a ptosis lid artifact and tests five and six are unreliable due to
high false positive rates. If all seven visual field tests are included in the analysis, the series seems to be improving (top), if the
lid artifact is excluded (middle), the series appears to be stable and if all three untrustworthy visual fields are excluded from
analysis, a significant visual field worsening becomes apparent (bottom).
17 8 Chapter 9 | I nterpretation of visual field progression

ADEQUATE TIME PERIOD FOR ANALYSIS

When choosing a time period for visual ield progression Another example is the situation in which a switch to
analysis, it is important to keep in mind that changes in more aggressive glaucoma treatment is made. This
treatment as well as surgical interventions can signii- switch can change the rate of progression. In that situ-
cantly change both visual ield severity and progression ation, it would be much harder to detect the change in
rates. For example, a patient with both cataract and rate if pre-treatment data are included. However, it should
glaucoma typically shows a significant improvement be noted that the impact of the switch in treatment on rate
of the MD after cataract surgery. This improvement of progression may only be assessed once a suficient
makes it challenging to assess glaucomatous progres- number of visual ield tests become available after the
sion rates after surgery, if pre-surgery visual ield data switch. Thus the new rate cannot be assessed immedi-
are included in the progression analysis. In those cases ately following the change in treatment.
only post-surgery data should be analyzed.

COMPARABLE TEST PARAMETERS

All visual ields included in a given progression analysis only one type of test strategy is used, the EyeSuite Pro-
must have the same test parameters in order to obtain gression Analysis allows inclusion of visual ield results
meaningful information about visual ield progression. obtained using different quantitative testing strategies.
Therefore, the EyeSuite Progression Analysis offers the The rationale for this is that even though the levels of
trend calculations only on visual ields tests that have accuracy between the TOP and the other strategies
been done with the same test pattern and stimulus and slightly differ, these effects are minimized at the level of
background characteristics. However, although ideally the global indices.⁹,¹⁰

DISTINCTION BETWEEN LOCAL

AND DIFFUSE CHANGE
IMPORTANCE OF DISTINCTION BETWEEN LOCAL AND
DIFFUSE CHANGE
When both local and diffuse defects are present, it is by both local and diffuse change, it is impossible to deter-
not only desirable to know whether there is change but mine the nature of the change by looking at MD alone.
also whether the detected change is local or diffuse.
This is important because local and diffuse change can For example, a patient may have both a local defect due
be caused by different clinical situations that may call to glaucoma and a diffuse defect due to a cataract. If
for different types of intervention (see TABLE 8-1 on the the MD is worsening in this patient, it is essential for a
etiology of local and diffuse loss). Because MD is affected clinician to know whether the cataract, the glaucoma or
Distinction between local and diffuse change 179

both are worsening. Examples of the presence of both tions in which MD is not suficiently sensitive to detect
local and diffuse change are presented in FIG 9-9. subtle local changes. This can for example be the case if
there is subtle local glaucomatous change, but the visual
In addition, the distinction between local and diffuse ield series also shows increased diffuse luctuation.
change is not only helpful in the presence of both a local An example of this is given in FIG 9-10.
and diffuse pathology, it is also very useful in all situa-

USE OF DIFFUSE DEFECT (DD) INDEX TO IDENTIFY

DIFFUSE CHANGE
To determine whether there is diffuse visual field of diffuse change. No symbol is displayed if there is no
change independent from the presence or absence of diffuse change, signiicant diffuse worsening is indicated
local change, Octopus perimeters use the global index by red downward arrows and significant diffuse im-
DD. This index represents the magnitude of the diffuse provement is shown by green upward arrows, similarly
defect and is calculated from the Defect Curve. For more to that described for the MD slope.
information on its design and deinition see BOX 7C.
Four typical situations (stable, local progression, diffuse
The DD Trend Analysis uses comparable deinitions as progression, local and diffuse progression) and the
the MD Trend Analysis but displays DD values on the respective behavior of the DD Trend Analysis are shown
Y-axis instead of MD values and thus allows assessment in FIG 9-8.

TYPICAL BEHAVIOR OF GLOBAL TREND ANALYSES FROM EARLY TO MODERATE DISEASE

MD sLV DD LD

Stable

Diffuse progression

Local progression

Diffuse & local progression

FIGURE 9-8 This figure illustrates the typical behavior of the four Global Trend Analyses in potentially worsening visual field
series from early to moderate disease. A q uick visual inspection of the four global indices provides a straightforward assess-
ment of whether a visual field series is worsening (MD worsening) and of whether the change is caused by diffuse worsening
(MD and DD worsening), local worsening (MD, LD, and sLV worsening) or both diffuse and local worsening (MD, DD, LD and
sLV worsening). Note that in more advanced disease (e.g., MD > 20 dB), with most visual field locations showing some degree
of sensitivity loss, MD and also DD shows worsening while LD and sLV show improvement.
18 0 Chapter 9 | I nterpretation of visual field progression

USE OF LOCAL DEFECT (LD) INDEX TO IDENTIFY LOCAL

CHANGE
To determine whether there is local visual ield change of localized change. No symbol is displayed if there is
independent from the presence or absence of diffuse no local change, red downward arrows indicate signii-
change, Octopus perimeters use the global index LD. cant local worsening and signiicant local improvement
This index represents the magnitude of the local defect is shown by green upward arrows, similarly to that de-
and is calculated from the Defect Curve. For more infor- scribed for the MD slope.
mation on its design and deinition see BOX 7D.
The typical behavior of the LD Trend Analysis in pro-
The LD Trend Analysis uses comparable deinitions as gressing from early to moderate disease (e.g., worsening
the MD Trend Analysis but displays LD values on the glaucoma) is shown in FIG 9-8.
Y-axis instead of MD values and thus allows assessment

USE OF SQUARE ROOT OF LOSS VARIANCE (sLV) TO

IDENTIFY LOCAL CHANGE
While the combined evaluation of the DD and LD Trend challenging to understand the visual ield change in
Analysis is suficient to distinguish between local and case of simultaneous local and diffuse change. For more
diffuse change, some users are more familiar with the information on the design and deinition of sLV see FIG
square root of Loss Variance(sLV) index. Octopus perim- 7-21 and TABLE 7-1. For more information on its clinical
eters therefore also provide a trend graphic of the index interpretation, see FIG 8-27.
sLV as an alternative to using the DD and LD Trend Anal-
ysis. This allows clinicians to choose the analysis they The sLV Trend Analysis uses comparable deinitions as
prefer to assess progression. the MD Trend Analysis but displays sLV values on the
Y-axis instead of MD values and thus allows distinction
The sLV global index provides a measure for the inho- between homogeneous and inhomogeneous change.
mogeneity of the visual ield. If a visual ield is normal, No symbol is displayed if there is no change; increasing
shows a diffuse defect or shows severe pathology (e.g., inhomogeneity is indicated by red downward arrows
MD > 20 dB), it is very homogeneous and sLV is low. On and increasing homogeneity is shown by green upward
the other hand, if a visual ield shows one or more local arrows, similarly to that described for the MD Trend
defects, it is more inhomogeneous and sLV is larger. sLV Analysis.
therefore increases if a local defect is increasing, and it
remains stable if a diffuse defect is increasing. While The typical behavior of the sLV Trend Analysis in pro-
this provides comparable information in a situation in gressing from early to moderate disease (e.g., worsening
which there is only local or only diffuse change, it becomes glaucoma) is shown in FIG 9-8.
Distinction between local and diffuse change 181

CLINICAL INTERPRETATION OF GLOBAL TREND ANALYSES

In clinical practice it is helpful to jointly consider the of a patient’s series of visual ields. Further analysis of
information from the four indices presented in the the individual graphs can then be performed given the
Global Trend Analysis. It is useful to assess the symbols clinical situation. Two clinical examples are shown in
marking signiicant change irst to get a quick overview FIG 9-9 and 9-10.

CASE EXAMPLE 1: PATIENT WITH BOTH PROGRESSING CATARACT AND GLAUCOMA

GLOBAL TREND ANALYSIS DESCRIPTION INTERPRETATION

MD sLV MD W orsening Fast (1.5 dB/year) worsening

Stable or overall Increasing/ decreasing
progression? inhomogeneity? of visual field series
0 DD Diffuse
0 worsening Both local and diffuse
worsening
sLV Stable
Progression of cataract and
15 LD Local glaucoma
worsening
25 15
2010 2011 2012 2013 2014 2010 2011 2012 2013 2014

Slope: 1.5 dB / Yr (p < 0.5%) Slope: 0.2 dB / Yr

DD LD
Diffuse progression? Local progression?
0

25 15
2010 2011 2012 2013 2014 2010 2011 2012 2013 2014

Slope 1.2 dB / Yr (p < 0.5%) Slope: 0.6 dB / Yr (p < 0.5%)

SERIES OF VISUAL FIELDS

Defect location & depth?

FIGURE 9-9 This figure illustrates the usefulness of look ing at the four global indices in combination. In this example, a patient
has both confirmed glaucoma and cataract. W hile the visual field shows overall significant worsening (MD worsening at p <
0.5% ), the MD Trend Analysis does not show which disease is progressing. An analysis of the Diffuse (DD) and Local (LD)
Trend Analyses shows both significant local and diffuse progression, suggesting that both glaucoma and the cataract are
progressing.
18 2 Chapter 9 | I nterpretation of visual field progression

CASE EXAMPLE 2: SUBTLE LOCAL GLAUCOMATOUS CHANGE AND MAINLY DIFFUSE FLUCTUATION

GLOBAL TREND ANALYSIS DESCRIPTION INTERPRETATION

MD sLV Clinically confirmed Slow (0.3 dB/year) local

Stable or overall Increasing/ decreasing pathology: glaucoma
progression? inhomogeneity? worsening of visual field series
0

0
MD Stable Some fluctuation

DD Stable Slow local glaucoma

progression
15
sLV Increasing
inhomogeneity
25 15
2010 2011 2012 2013 2014 2010 2011 2012 2013 2014 LD Local
Slope: 0.4 dB / Yr Slope: 0.5 dB / Yr (p < 0.5%) worsening

DD LD
Diffuse progression? Local progression?
0

15

25 15
2010 2011 2012 2013 2014 2010 2011 2012 2013 2014

Slope: 0.1 dB / Yr Slope: 0.3 dB / Yr (p < 2%)

SERIES OF VISUAL FIELDS

Defect location & depth?

FIGURE 9-10 This glaucoma patient shows a mark ed nasal step and some diffuse visual field loss in visual fields 3 and 4
in the series of Grayscale (Comparisons) representation. Look ing solely at MD change, the visual field series appears to be
stable (no symbol). Nevertheless, the MD Trend Analysis also shows an outlier on the 3rd test, which is also present in the DD
Trend Analysis suggesting this is caused by diffuse fluctuation. Assessment of the DD Trend Analysis (no change), sLV Trend
Analysis (significant worsening at p < 1% ) and LD Trend Analysis (significant worsening at p < 5% ) reveals no diffuse change
but significant local change. In conclusion, in this situation MD is too affected by diffuse fluctuation to show the significant but
local worsening of the nasal step defect. Thus, the additional assessment of local and diffuse change in this situation is more
sensitive in detecting subtle local change than the assessment of only the MD Trend Analysis.
Cluster Trend and Corrected Cluster Trend Analysis 183

CLUSTER TREND AND CORRECTED

CLUSTER TREND ANALYSIS
IMPORTANCE OF ASSESSING CLUSTER PROGRESSION
IN GLAUCOMA
Typical glaucomatous defects caused by localized retinal For example, to determine whether there is a corre-
nerve iber damage, as well as some visual ield defects sponding structural change in glaucoma to conirm a
caused by optic nerve damage, consist of a cluster of suspected glaucomatous change, it is helpful to know in
adjacent defective visual ield locations (FIG 5-1) that which area of the visual ield the change is happening.
correspond to the path followed by the retinal nerve iber In addition, in a constricted glaucomatous visual ield with
bundles in the retina (see step 5 in Chapter 8). Localized many visual ield locations showing absolute defects
visual ield progression therefore typically occurs in a (i.e., sensitivity thresholds of 0 dB), progression in the re-
cluster of visual ield locations. maining central visual ield of a patient is of key impor-
tance for quality of life but may not be apparent from
However, if localized glaucomatous progression is small the MD Trend Analysis, due to its relative insensitivity
and there is additional luctuation, the global index MD in detecting localized change.
may not be sensitive enough to detect that subtle clus-
ter change because MD is an average of the sensitivity It is thus helpful to assess Cluster MD progression in
loss of the whole visual ield. While in some instances addition to the global indices to detect subtle localized
looking at local change using the LD or sLV indices can visual field change in glaucoma as well as to receive
lead to the detection of such change, spatial information additional spatial information about where the change
about where the change occurs is missing. is happening. This is the purpose of both the Cluster and
Corrected Cluster Trend Analysis.

CLUSTER AND CORRECTED CLUSTER TREND ANALYSIS

Cluster Trend Analysis (CTA) is a trend analysis based Both types of Cluster Trend Analysis employ the same
on the single ield Cluster Analysis whose design and statistical analysis also used in the global MD Trend
deinitions have already been explained in FIG 7-12 and Analysis and use comparable symbols to indicate sig-
7-13 and BOX 7B and whose clinical interpretation and niicance of change. However, instead of looking for
usefulness have already been shown in FIG 8-20 and signiicant MD change over time, they are looking for
8-21 and BOX 8B. The Corrected Cluster Trend Analysis signiicant Cluster or Corrected Cluster Mean Defect
(CCTA) is very similar to CTA, but is based on the Correct- (MD) change over time.
ed Cluster Analysis (see FIG 7-20) which eliminates the
inluence of diffuse defect.
18 4 Chapter 9 | I nterpretation of visual field progression

CLUSTER TREND AND CORRECTED CLUSTER TREND – INTERPRETATION AID

CLUSTER TREND DEFINITION INTERPRETATION

Probability of stable visual field series

showing this result
4.1
2.1

No symbol p > 5% Stable

-0.8 6.7
2.6
0.4
1.0 0.4
W orsening at p < 5% Likely worsening cluster

0.7 W orsening at p < 1% Highly likely worsening cluster

0.6

Improvement at p < 5% Likely improving cluster

Improvement at p < 1% Highly likely improving cluster

CORRECTED CLUSTER TREND
Floor effect Maximum cluster loss
(Cluster MD > 20 dB, (No further measurement of progression possible
no significant progression) in this cluster)
3.5
1.5
6.7 Cluster MD Slope Cluster MD change in dB/year
-1.4 6.0
[ dB/ year]
2.0
-0.2
-0.3 -0.2 6.0 Corrected Cluster Corrected Cluster MD change
MD Slope [ dB/ year] in dB/year
0.0
-0.1

FIGURE 9-11 The Cluster Trend representations display 10 visual field clusters that spatially correlate with retinal nerve fiber
bundles. In each cluster, a Cluster MD change in dB/ year is indicated. Significant Cluster MD worsening is mark ed with a red
downward arrow, whereas significant Cluster MD improvement is mark ed with green upward arrows. Stable clusters do not
have a symbol and clusters which show a floor effect are mark ed with a black symbol.

CTA and CCTA also use the red downward arrows and more clinically meaningful if it is spatially correlated with
green upward arrows to show signiicant cluster wors- another meaningful cluster defect or if it correlates with
ening or improvement. However, the graphical display a signiicant structural change.
is different from the MD Trend Analysis. The individual
Cluster MDs are not shown in a two-dimensional trend Similar to Cluster Analysis (see BOX 8B), CTA has been
graph. Instead, both the Cluster MD change in dB/year shown to be highly sensitive in detecting subtle, early
and a symbol indicating the signiicance of this change glaucomatous change and has been shown to be more
are displayed in each of the 10 clusters as shown in sensitive in detecting change than MD Trend Analysis
FIG 9-11. and local event analysis11-13 (not available as a statis-
tical tool in the EyeSuite Progression Analysis).
Similar to the interpretation of Cluster Analysis, some
caution is essential in the clinical interpretation of CTA These indings can be explained with the same rationale
and CCTA. This is because one random cluster showing a used to explain why Cluster Analysis is highly sensitive in
p value smaller than 5% is expected to occur even in sta- detecting early glaucomatous defects. Because glauco-
ble visual ields. Thus, a signiicant cluster defect is much matous change is mostly local, the averaging used to de-
Cluster Trend and Corrected Cluster Trend Analysis 185

rive the MD global index reduces the chances of detecting hand, single point event analysis is too inluenced by
early localized change (FIG 9-12 and 9-13). On the other luctuation to detect signiicant change early.

ILLUSTRATION OF THE USEFULNESS OF CLUSTER TREND ANALYSIS

EYESUITE PROGRESSION ANALYSIS

GLOBAL TREND ANALYSIS CLUSTER TREND ANALYSIS

MD sLV CLUSTER TREND

Stable or overall Increasing/ decreasing Cluster MD progression?
progression? inhomogeneity?
0

0
Significant superior
paracentral, superior
and infero-temporal
progression
15

1.6
25 15 0.5
2011 2012 2013 2014 2011 2012 2013 2014

Slope: 0.5 dB / Yr Slope: 0.3 dB / Yr

0.6 0.0
DD LD 1.4
Diffuse progression? Local progression?
0 -0.6
0 0.5 1.9

-0.1
15
-0.7

25 15
2011 2012 2013 2014 2011 2012 2013 2014

Slope: 0.0 dB / Yr Slope: 0.6 dB / Yr (p < 0.5%)

SERIES OF VISUAL FIELDS

Defect location & depth?

FIGURE 9-12 The usefulness of Cluster Trend Analysis (CTA) in a case which shows a considerable amount of fluctuation
is visible in the data. This visual field series of a glaucoma patient appears to be stable (no symbol indicating change) on
the global index MD, but shows local worsening on the LD index. Using CTA, significant worsening (red downward arrow) is
apparent in the superior paracentral, superior and infero-temporal clusters indicating clear local worsening. In this situation,
CTA is more sensitive in detecting progression than MD and provides additional information about the location of progression
compared to the LD index.
18 6 Chapter 9 | I nterpretation of visual field progression

ILLUSTRATION OF THE USEFULNESS OF CLUSTER TREND ANALYSIS IN ADVANCED DISEASE

EYESUITE PROGRESSION ANALYSIS

GLOBAL TREND ANALYSIS CLUSTER TREND ANALYSIS

MD sLV CLUSTER TREND

Stable or overall Increasing/ decreasing Cluster MD progression?
progression? inhomogeneity?
0

Floor effect
15

-0.1
25 15 0.1
2010 2011 2012 2013 2014 2010 2011 2012 2013 2014

Slope: 0.2 dB / Yr Slope: 0.0 dB / Yr

0.9 0.7
DD LD -0.6
Diffuse progression? Local progression?
0 -0.3
0 0.1 -0.6

1.6
15
0.2

25 15 Significant inferior
2010 2011 2012 2013 2014 2010 2011 2012 2013 2014
progression
Slope: 0.0 dB / Yr Slope: 0.2 dB / Yr

SERIES OF VISUAL FIELDS

Defect location & depth?

FIGURE 9-13 This example presents the visual fields of a glaucoma patient with a severe superior altitudinal defect and no
remaining sensitivity in most of the upper visual field (floor effect, no further progression can be detected). All four global
indices are stable with no symbol indicating change. However, using the Cluster Trend Analysis, significant localiz ed worsening
(red downward arrow) is apparent in the inferior cluster. In such advanced situations, Cluster Trend Analysis can assist in the
detection of progression in areas with remaining sensitivity, which is important for the management of the patient.
Polar Trend Analysis 187

POLAR TREND ANALYSIS

IMPORTANCE OF ESTABLISHING A RELATIONSHIP
BETWEEN STRUCTURAL AND FUNCTIONAL PROGRESSION
In eyes with early glaucomatous damage or only subtle Because visual ield damage is often detected in a repre-
progression, detection of pathological changes is chal- sentation of a retinal location while structural damage
lenging. Therefore, it is often useful to consider both is evident at the optic disc, there is a need to use a repre-
functional and structural change (i.e., neuroretinal sentation that links the structural to the functional visual
rim tissue loss; decrease of retinal nerve fiber layer ield progression. This is the purpose of Polar Trend
thickness. Analysis.

USE OF POLAR TREND ANALYSIS TO ASSIST IN

THE DETECTION OF GLAUCOMATOUS STRUCTURAL
PROGRESSION
Polar Trend Analysis is based on Polar Analysis, whose bundles arrive at the margin of the disc. It does so by
design and deinitions have already been shown in FIG employing the same trend analysis approach also used
7-14 and 7-15 and whose clinical interpretation and use- in the global MD Trend Analysis (see FIG 9-3 and 9-5 and
fulness have been presented in FIG 8-23 and 8-24. BOX 9A), but applies it to sensitivity loss at each test lo-
cation (pointwise trend analysis). For more information
It graphically represents change at each visual ield test on the design of Polar Trend Analysis, refer to BOX 9B.
location where the corresponding retinal nerve fiber

THE DESIGN OF POLAR TREND ANALYSIS BOX 9B

Polar Trend Analysis performs pointwise trend analysis on sensitivity loss data to determine the trend
line but not the signiicance of the slope for each visual ield location individually. This is illustrated in
the graphic in this box, which uses the example of one superior nasal test location circled in red in the
Grayscale representation.
However, the graphical display of Polar Trend Analysis is fundamentally different from the other
representations discussed previously. Instead of using the slope to determine a rate of change, the
trend line is used to determine a best itted sensitivity loss for the irst (blue point in the graphic in this
box) and the last (yellow point) of the visual ield tests. It should be noted that these two data points
are based on the trend line at the respective test dates, not on the individual visual ield test result at a
given test date.
These two itted sensitivity loss values are then marked in the same Polar grid also used for Polar
Analysis and connected by a straight line at the position where the corresponding nerve iber bundles
of the test location arrive at the margin of the disc. If there is worsening between that irst and last
itted sensitivity loss, then the bar is drawn in red, while it is drawn in green if there is improvement.
18 8 Chapter 9 | I nterpretation of visual field progression

THE DESIGN OF POLAR TREND ANALYSIS

SENSITIVITY LOSS POLAR TREND ANALYSIS

AT ONE TEST LOCATION AT ONE TEST LOCATION

0 Best fitted first

sensitivity loss
one test location (dB)
Sensitivity loss at

S
30 20 10
[dB] N T
I
15
Best fitted last
sensitivity loss

25
2002 2003 2004 2005

Test date (years)

SERIES OF VISUAL FIELDS

Polar Trend Analysis performs point-wise trend analysis to determine the trend line at each visual ield
location. The individual sensitivity losses from one test location over time, shown as red circles in the series
of visual ields (bottom) are used to determine the trend line of the sensitivity losses at that test location
(top left). The trend line, and not on the actual test data (gray squares), is used to determine the initial
(blue) and last sensitivity loss (yellow). These sensitivity losses are used as the start and end location of
the progression bar in the Polar Trend Analysis (top right). Overall worsening is illustrated with a red
bar (shown in this example), and overall improvement is illustrated with a green bar (not shown in this
example). The length of the bar indicates the magnitude of change.

Progression (worsening) is represented by a red bar, the change is not given numerically, the approximate change
length of which corresponds to the best-itted change of each defect can be identiied on the graph in dB. A
in the sensitivity loss in dB. Improvement is similarly gray band in the center indicates approximate normal
represented using a green bar. Though the quantity of ranges for those bars (FIG 9-14).
Polar Trend Analysis 189

POLAR TREND ANALYSIS – INTERPRETATION AID

POLAR TREND DEFINITION INTERPRETATION

Indication of change at each test

location proj ected onto optic disc

Sensitivity loss [ dB] Worsening location

• Length of bar indicates total • Short bar – small worsening
S change from first to last • Long bar – large worsening
30 20 10 N T selected test
[dB]
I

Sensitivity gain [ dB] Improving location

• Length of bar indicates total • Short bar – small improvement
change from first to last • Long bar – large improvement
selected test

Normal range

FIGURE 9-14 Polar Trend Analysis representation proj ects local progression per test location onto the optic disc to allow for
easy link ing with structural results. Red bars indicate worsening while green bars indicate improvement. The starting and end
location point (i.e. the length) of each bar is based on the loss indicated by the local trend line between the first and the last
examination.

Clinical interpretation of Polar Trend Analysis is straight- potential structural progression. However, it is import-
forward and based solely on the graphical representation. ant to note, no rates of progression or signiicance of
The longer the bar, the more absolute change has occurred progression are provided by Polar Trend Analysis. For
during the time period of interest and the further away an exact evaluation of these parameters, one can refer
the bar is located from the center, the more damage was to Cluster Trend and Corrected Cluster Trend Analyses.
already present at a given test location at the time of It is important to remember that those representations
the irst test. are oriented as visual ields and not as structural data.
This means that related defects will be positioned at the
If there are many red bars indicating worsening clus- location lipped vertically across the horizontal midline.
tered at one optic disc location, this indicates a visual
ield worsening at that position. One can determine Polar Trend Analysis has been shown to correlate well
whether a corresponding structural change at that same with structural progression data14 and is therefore a very
position is present. Defect progression on the Polar Trend useful and quick tool for assistance with the combined
Analysis report can be considered as a warning message evaluation of both structural and functional progres-
for localized visual ield progression, which may draw sion. A clinical case is illustrated in FIG 9-15.
the clinicians’ attention to the spatially corresponding
19 0 Chapter 9 | I nterpretation of visual field progression

ILLUSTRATION OF THE USEFULNESS OF POLAR TREND ANALYSIS

GLOBAL TREND ANALYSIS CORRECTED CLUSTER POLAR TREND

TREND ANALYSIS ANALYSIS
Fast superior
& paracentral
MD Mean defect sLV Loss variance progression
0
2.6
0 2.5

0.4 -0.5
1.7 S
30 20 10
N T
0.7 [dB]
I
-0.1 0.2

15
0.0
-0.0
MD change
25 1.0 dB/ year 15
2013 2013
Slope: 1.0 dB / Yr (p < 0.5%) Slope: 0.4 dB / Yr (p < 0.5%)

OCT
DD Diffuse defect LD Local defect Significant further
0 RNFLT decrease
0 inferotemporally
2008 2013 and superotemporally

25 15
2013 2013
Slope: 0.2 dB / Yr Slope: 1.1 dB / Yr (p < 0.5%)

SERIES OF VISUAL FIELDS

2008 2013

FIGURE 9-15 This glaucoma patient shows significant local visual field worsening (MD, LD and sLV worsening at p < 1% )
over a period of 5 years starting from the superior paracentral and superior nasal step areas and expanding to the inferior
paracentral area, while deepening at the original defect locations (significant corrected cluster worsening in these areas). Polar
Trend Analysis displays strong supero- and infero-temporal worsening. Look ing at the change on the OCT retinal nerve fiber
layer thick ness between 2008 and 2013 (supero- and infero-temporal structural progression), there is a clear spatial relationship
between structural and functional change, thus confirming that these changes stem from glaucoma.
References 191

REFERENCES
1. Tanna AP, Bandi JR, Budenz DL, et al. Interobserver agreement and intraobserver reproducibility of the subjective
determination of glaucomatous visual ield progression. Ophthalmology. 2011;118:60-65.
2. Tanna AP, Budenz DL, Bandi J, et al. Glaucoma Progression Analysis software compared with expert consensus opinion
in the detection of visual ield progression in glaucoma. Ophthalmology. 2012;119:468-473.
3. Viswanathan AC, Crabb DP, McNaught AI, et al. Interobserver agreement on visual ield progression in glaucoma: a
comparison of methods. Br J Ophthalmol. 2003;87:726-730.
4. Lin AP, Katz LJ, Spaeth GL, et al. Agreement of visual ield interpretation among glaucoma specialists and comprehensive
ophthalmologists: comparison of time and methods. Br J Ophthalmol. 2011;95:828-831.
5. Iester M, Capris E, De Feo F, et al. Agreement to detect glaucomatous visual ield progression by using three different
methods: a multicentre study. Br J Ophthalmol. 2011;95:1276-1283.
6. European Glaucoma Society. Terminology and Guidelines for Glaucoma. 4th ed. Savona: PubliComm; 2014.
7. Taketani Y, Murata H, Fujino Y, Mayama C, Asaoka R. How Many Visual Fields Are Required to Precisely Predict Future Test
Results in Glaucoma Patients When Using Different Trend Analyses? Invest Ophthalmol Vis Sci. 2015;56:4076-4082.
8. Chauhan BC, Garway-Heath DF, Goñi FJ, et al. Practical recommendations for measuring rates of visual ield change in
glaucoma. Br J Ophthalmol. 2008;92:569-573.
9. Anderson AJ. Spatial resolution of the tendency-oriented perimetry algorithm. Invest Ophthalmol Vis Sci. 2003;44:
1962-1968.
10. Maeda H, Nakaura M, Negi A. New perimetric threshold test algorithm with dynamic strategy and tendency oriented
perimetry (TOP) in glaucomatous eyes. Eye (Lond). 2000;14:747-751.
11. Naghizadeh F, Holló G. Detection of early glaucomatous progression with Octopus cluster trend analysis. J Glaucoma.
2014;23:269-275.
12. Aoki S, Murata H, Fujino Y, et al. Investigating the usefulness of a cluster-based trend analysis to detect visual ield
progression in patients with open-angle glaucoma. Br J Ophthalmol. 2017;doi: 10.1136/bjophthalmol-2016-310069.
13. Gardiner SK, Mansberger SL, Demirel S. Detection of functional change using Cluster Trend Analysis in glaucoma. Invest
Ophthalmol Vis Sci. 2017;58:BIO180-BIO190.
14. Holló G, Naghizadeh F. Evaluation of Octopus Polar Trend Analysis for detection of glaucomatous progression. Eur J
Ophthalmol. 2014;24:862-868.
 193

CHAPTER 10
NON-CONVENTIONAL PERIMETRY

INTRODUCTION
Static Standard Automated Perimetry (SAP, alternative- variability in patient responses in areas of significant
ly called white-on-white perimetry), which uses a white vision impairment or low vision and 2) there is a marked
Goldmann size III stimulus presented on a white back- loor effect in areas of signiicant vision impairment or
ground, is by far the most commonly used type of peri- low vision.
metric test today. It is the standard of care to detect and
follow glaucoma. The white stimulus stimulates nearly Other forms of perimetry have been developed to allow
all types of retinal ganglion cells and as a result the test has for earlier detection and to overcome the shortcomings
a large dynamic range. Nevertheless, it would be desirable of SAP. Non-conventional perimetry includes function-
to have a more sensitive test than SAP for early detection speciic perimetric tests that use stimuli which target
of irreversible vision loss in diseases such as glaucoma. speciic pathways and visual functions (e.g., licker) and
also white-on-white perimetry performed with the larger
Furthermore, the following shortcomings are associat- size V stimulus, which provides a useful alternative for
ed with SAP using a size III stimulus: 1) there is large testing in areas of vision impairment or low vision.
194 Chapter 10 | Non-conventional perimetry

FUNCTION-SPECIFIC PERIMETRY
RATIONALE FOR USING FUNCTION-SPECIFIC PERIMETRY
Different Octopus perimeter models offer different types While the stimuli used in SWAP, Flicker perimetry and
of function-speciic stimuli. Pulsar perimetry uses a lick- Pulsar perimetry differ substantially from each other, the
ering stimulus with concentric rings changing in both same rationale was used to develop them. These tests are
spatial resolution and contrast that resembles a bullseye. designed to overcome the redundancy of the visual sys-
Flicker perimetry uses a white lickering stimulus present- tem by selectively stimulating a subset of retinal cells and
ed on a white background. Short-Wavelength Automated as a result get a more sensitive response to early changes
Perimetry (SWAP - alternatively called blue-on-yellow (FIG 10-1). This rationale is based on the hypothesis that
perimetry) uses a blue (short wavelength) stimulus pre- different types of retinal ganglion cells process different
sented on a yellow background. Similar to SAP, all these visual functions, but nearly all retinal ganglion cells can
tests are based on functional decline due to retinal detect the white stimulus used in SAP. While some cells
ganglion cell loss in glaucoma. are adversely affected by pathology such as glaucoma,

ILLUSTRATION OF THE RATIONALE BEHIND FUNCTION-SPECIFIC PERIMETRY

STIMULUS TYPE OF RETINAL NORMAL EARLY PATHOLOGY

GANGLION CELLS

SAP

Parvocellular

Koniocellular

Magnocellular

Pulsar

Magnocellular

FIGURE 10-1 Function-specific perimetry has been developed to reduce the redundancy within the visual system with the
goal of detecting visual field loss earlier. The idea is based on the hypothesis that white light universally stimulates nearly all
retinal ganglion cell types. The loss of a few retinal cells should therefore be easily compensated by the remaining cells, as the
example with the SAP stimulus (top) illustrates. The white stimulus stimulates many retinal cells and even when several are
dysfunctional, the white stimulus (white circle) is still seen. In function-specific perimetry, only one cell type is predominantly
stimulated. In the example with the Pulsar stimulus (bottom), there is no remaining functional magnocellular cell that can be
stimulated by the Pulsar stimulus. As a result, the stimulus is not seen.
F unc tion- speci fic perim etry 195

other neighboring cells may still detect the SAP stimulus. pathology such as glaucoma, there are a smaller number
This presumably makes the SAP test less sensitive to early of cells that are able to detect the function-speciic stim-
visual ield loss. To give a simple analogy, it is as though ulus, making the test more sensitive to early visual ield
one person out of the 20 who promised to help you move loss. Using the previous analogy, this would translate into
calls in sick on moving day. The other 19 helpers can having one person out of only two cancel on moving day.
effectively carry on the task and the impact of the one There is only one person to help with the move and the
missing person is not felt too strongly. task becomes much more dificult.

In contrast, function-specific perimetry targets only The function-speciic stimuli currently available have all
a subset of retinal ganglion cells. It is assumed that been developed for early glaucoma detection, but have
if a few cells in this subset are adversely affected by also been used for other diseases.

USE OF FUNCTION-SPECIFIC PERIMETRY IN CLINICAL

PRACTICE
While many studies have reported that function-spe- While there are distinct normative databases for each
ciic perimetry detects glaucomatous vision loss earlier function-speciic stimulus as well as for SAP, it is es-
than SAP,¹,² other studies have found no such effect.4,5 sential to consider that function-speciic perimetry has
As a result, experts have not yet reached a consensus on a smaller dynamic range than SAP. Therefore, while
whether function-specific perimetry provides added normal subjects may show comparable responses on
value in comparison to SAP. all tests, patients with more advanced disease are likely
to show visual ield defects that appear more severe on
When making a decision about whether or not to use function-speciic perimetry due to the smaller dynamic
function-speciic perimetry, it is essential to keep in mind range.
that the quantitative results cannot be directly compared
with white-on-white perimetry. While SAP is the recom- Consequently, function-speciic perimetry cannot be
mended standard, one may choose either SAP or one of used through all disease stages. If there is advanced
the function-speciic perimetry tests as a default test for disease, one should use SAP. If function-speciic perime-
disease detection. If time allows, one might choose to try is chosen as a default for disease detection, switching
perform an additional test, particularly in situations of to SAP is recommended for follow-up at some point. In
uncertainty (i.e., to conirm suspected but unconirmed order to avoid a lack of historic reference data, it may be
visual ield loss as shown in the example in FIG 10-2). best to switch to SAP early in the follow-up process.
196 Chapter 10 | Non-conventional perimetry

EXAMPLE OF SAP AND FUNCTION-SPECIFIC PERIMETRY IN THE SAME EYE

GRAYSCALE (CO) COMPARISONS PROBABILITIES

+ +

+ + + + 7 +

8 +
+ + + +
+ + + + +
+ + + + + +
SAP

+ + + +
+
+ + + +
+ + + + + +
+ + + + +
+ + + 7
+ +

+ + + + + +

+ +
FUNCTION-SPECIFIC PERIMETRY

7 7

+ + 7 9 6 7

7 11
+ + 11 7
+ + 5 7 8
+ +
+ + + + + 5 8 11
+
+ + + + + + 5 10
+ +
+ + + + 10
+ + + 7
+ +

+ + + + + +

+ +

FIGURE 10-2 The same patient with an early glaucomatous defect is tested twice, once with the SAP test (top) and once with
the function-specific Pulsar stimulus (bottom). Wh ile SAP does not show a statistically significant defect in this patient, there
is a clear defect visible when using function-specific Pulsar perimetry. Note that the locations with p < 5% for SAP are within
the area in which the defect is present for function-specific perimetry.

PULSAR PERIMETRY
The Pulsar stimulus is a function-speciic stimulus that two images alternate at a frequency of 10 Hz over 500 ms.
tests both licker sensitivity and contrast sensitivity. It If licker sensitivity is reduced, the visual system cannot
has been developed speciically for early glaucoma de- detect the change between the phase and counter-phase
tection and has been shown to be both sensitive and images. As a result, the phase and counter-phase images
speciic in the detection of early glaucoma.1-3 It is a very are perceived as a single image. Because the average
patient-friendly perimetric test. intensity of the rings of the phase and counter-phase
images are equal to the mean intensity of the back-
The stimulus used in Pulsar perimetry consists of a ring ground, the Pulsar stimulus blends with the background
pattern with a diameter of 5° of visual angle, which is and is not visible anymore (FIG 10-3). However, if licker-
more than 10 times larger in radius and 100 times larger sensitivity is not affected, the visual system distinguishes
in area than the white size III stimulus used in SAP. The between the phase and counter-phase images and the
Pulsar stimulus consists of phase and counter-phase im- Pulsar stimulus is perceived like a pulsating ring pattern,
ages. This means that light rings on the phase image are similar to the ripple pattern generated if a water drop
displayed as dark rings on the counter-phase image. The enters a smooth water surface.¹
F unc tion- speci fic perim etry 197

DESIGN OF THE PULSAR STIMULUS

PHASE COUNTER-PHASE

HEALTHY DISEASED
flick er-sensitive cells flick er-sensitive cells

Seen Not seen

FIGURE 10-3 The Pulsar stimulus consists of a flick ering phase and counter-phase image. If the function of the flick er-sen-
sitive cells is intact, the stimulus can be seen (bottom left). If it is decreased, then the phase and counter-phase images are
perceived as one image that eq uals the back ground and is invisible (bottom right).

The Pulsar test uses a very patient-friendly stimulus. It is In addition, sensitivity thresholds can also be deter-
easy to instruct the patients on how to perform the test mined. Pulsar perimetry employs its own unit scale, the
(seen or not seen) and patients have more conidence src scale, consisting of 36 distinct steps, with increased
about seeing the stimulus both because of its large size spatial resolution (sr) and contrast (c) with each step
and perceived motion. As a result, Pulsar perimetry (FIG 10-4). The results of this threshold test are then
has low test-retest variability and a minimal learning displayed as any SAP result and all the visual ield repre-
effect.6,7 These features make it very suitable for screening sentations presented in Chapters 7-9 are available. Pulsar
purposes. perimetry uses all representations available for SAP.

SENSITIVITY THRESHOLDS WITH PULSAR PERIMETRY

LESS VISIBLE MORE VISIBLE

CONTRAST
RESOLUTION
SPATIAL

FIGURE 10-4 Pulsar perimetry allows the determination of sensitivity thresholds by showing stimuli of both increasing spatial
resolution (sr) and contrast (c). Sensitivity thresholds are expressed in src.
198 Chapter 10 | Non-conventional perimetry

FLICKER PERIMETRY
Flicker perimetry is similar to Pulsar perimetry in that it stimulus that the perimeter can display) lickers over a
stimulates licker sensitive cells and has been created for period of 1 second and the patient is instructed to press
early glaucoma detection. However, the stimulus design the response button only when the stimulus seems to
is fundamentally different from that of Pulsar perimetry. licker (FIG 10-5). The licker frequency ranges from
Flicker perimetry determines the critical fusion fre- very fast (approximately 50 cycles per second) to slow
quency (CFF), or in other words, the frequency at which (i.e., 1-5 cycles per second). The CFF represents the sen-
the licker appears to fuse into continuous steady light. sitivity threshold of Flicker perimetry (FIG 10-6) and is
In this test, a white stimulus of Goldmann size III with expressed in Hertz (Hz).
a stimulus intensity of 4,000 asb (i.e., the most intense

DESIGN OF THE FLICKER STIMULUS

Do you see the

Stimulus stimulus flick er?

Time 1 Time 2
Fixation

ON OFF

Flick ering
4,000 asb

Time (t) = 1 s
Freq uency = 4 stimuli/s = 4 Hz

FIGURE 10-5 Flick er perimetry uses a flick ering white stimulus (siz e III) of 4,000 asb on a white back ground that flick ers at
different temporal freq uencies. The freq uency is expressed in Hertz , a unit that defines how many times the stimulus is flick ering
per second. In the example above, the stimulus has a freq uency of 4 Hz .

Flicker perimetry was shown to be both sensitive and are minimally inluenced by media opacities stemming
speciic in the detection of early glaucoma.8-10 One of its from pathologies such as cataracts or refractive errors,
major additional advantages is that sensitivity thresholds for example.10,11
F unc tion- speci fic perim etry 199

Flicker perimetry is more demanding of patients com- mended only for patients who perform very well on
pared to Pulsar perimetry, because they must pay atten- perimetry. In these patients, it is a useful perimetric test.
tion to both the presence of a stimulus and whether it
is lickering or not. Thus, careful patient instruction and BOX 10A provides practical guidance on how to best
observation are even more essential in licker perimetry perform licker perimetry.
than in other perimetry forms. Its use is therefore recom-

SENSITIVITY THRESHOLDS WITH FLICKER PERIMETRY

LESS VISIBLE MORE VISIBLE

High frequency Low frequency

FREQUENCY
(HZ)

t t t

FIGURE 10-6 In flicker perimetry, stimuli flicker from high frequencies (50Hz, flicker is more difficult to see) to low frequencies
(1-5 Hz, flicker is easier to see) to determine the Critical Fusion Frequency (i.e., the frequency in Hertz (Hz) at which a flickering
stimulus appears to fuse into continuous steady light). The CFF defines the sensitivity threshold at a given location.

HOW TO PERFORM RELIABLE FLICKER PERIMETRY BOX 10A

Most points highlighted in Chapter 3 on how to run a reliable visual ield test also apply to licker
perimetry. However, there are some speciic points to which particular attention should be given.
First, patient instructions need to be slightly adapted and should include a description of a lickering
stimulus. An example referring to old television sets or to a candle in the wind might prove helpful.
It might also be useful to describe that the test examines one’s ability to recognize when lights go on
and off when they are switched rapidly. It also needs to be stressed that all stimuli are visible for a full
second, but that the patient should only respond when a lickering motion is perceived and not upon
the mere presence of a stimulus. It might be worth starting with a practice test to make sure that the
patient understands the task.
It is also recommended that the examiner pays very close attention to ixation losses, because patients
are more likely to search for stimuli in licker perimetry than in other forms of perimetry because of its
inherent challenges.
200 Chapter 10 | Non-conventional perimetry

SHORT WAVELENGTH AUTOMATED PERIMETRY (SWAP)

Short Wavelength Automated Perimetry (SWAP) is com- receive input from blue-sensitive retinal ganglion cells)
monly referred to as blue-on-yellow perimetry, because while the intense yellow background is used to suppress
it displays a large blue (short wavelength) stimulus of (i.e., adapt or fatigue) the relative sensitivity of both the
Goldmann size V on a bright yellow background with a green (M-cones for “middle” wavelength cones) and the
luminance of 315 asb (100 cd/m²).12 The patient is asked red cones (L-cones for “long” wavelength cones). Sensitivity
to respond whenever a blue stimulus is visible. thresholds are determined by increasing the luminance
(i.e., light intensity) of the blue stimuli from less visible
SWAP is designed to elicit a response from the blue sen- to more visible and are expressed in dB (FIG 10-7). Never-
sitive pathway (S-cones for “short” wavelength cones and theless, the numerical dB values are not directly compa-
the koniocellular cells in the lateral geniculate body that rable to those obtained with SAP.

DESIGN OF SHORT WAVELENGTH AUTOMATED PERIMETRY (SWAP)

LESS VISIBLE MORE VISIBLE

LUMINANCE
STIMULUS

FIGURE 10-7 SWAP allows the determination of sensitivity thresholds by showing blue stimuli of increasing light intensity on
an intense yellow background. Sensitivity thresholds are expressed in dB but are not directly comparable to results from SAP.

Like other types of function-specific perimetry, SWAP addition, the patient’s eye needs to adapt to the very in-
has also been shown to be useful for early glaucoma tense background for several minutes before starting the
detection.13,14 Unlike licker perimetry, it is inluenced test in order to avoid false results. This light adaptation
by media opacities and blur.15 is time-consuming and makes SWAP an overall longer
test to perform than SAP.
The task of performing SWAP is easy to understand for
the patients (seen or unseen). Nevertheless, this test is However, given a patient who is able to perform the
challenging for patients because the intensity of the yellow test reliably, SWAP is a useful perimetric test. BOX 10B
background makes it dificult to perceive the blue stimuli. provides practical guidance on how to best administer a
This results in increased test-retest variability.16,17 In SWAP test.
Stimulus V for patients with low vision 201

HOW TO ADMINISTER A RELIABLE SWAP TEST BOX 10B

Most points highlighted in Chapter 3 on how to run a reliable visual ield test also apply to SWAP
perimetry, However, particular attention needs to be given to some speciic points.
For SWAP, allow the patient’s eye to adapt to the very intense background for several minutes before
starting the test in order to avoid untrustworthy results. Patients should be instructed to press the
response button when they see a blue light presented anywhere in the bowl. The examiner should let
the patient know that the color of the stimulus may appear to be slightly different from blue, as some
patients report seeing the stimulus as bluish or purplish.
SWAP is a more challenging test to perform than SAP. The examiner should closely monitor the patients
as they are taking the test, to identify any need to rest. Particular attention should also be paid to
reliability indices to ensure that patients are performing the test to the best of their ability. It is often
helpful to provide a brief demonstration test to familiarize the patient with the test procedure.

STIMULUS V FOR PATIENTS WITH

LOW VISION
There is a limit to the visibility of the standard size III dynamic range in regions of poor vision, the Goldmann
white perimetric stimulus in patients with signiicantly stimulus V can be used. When this stimulus, which is 16
impaired sensitivity. This is because there are no longer times larger in area than the size III stimulus (FIG 10-8),
enough intact cells to elicit a response to a stimulus even is displayed for a longer period of time (i.e., 200 ms),
though the patient has some vision remaining (FIG 10-9). it provides a useful alternative perimetric stimulus for
In order to overcome this loor effect and to increase the patients with severe visual ield loss.

GOLDMANN STIMULUS SIZE III VS V FOR LOW VISION

III 0.43° V 1.7°

FIGURE 10-8 The Goldmann stimulus size V used for patients with severe vision loss is 16 times larger in area than the stan-
dard Goldmann size III. Both are displayed with the same intensities on the same white background, but due to its greater size,
the size V stimulus is more visible for low-vision patients than the size III.

Because the larger stimulus V reaches more intact cells, longer can,18 as illustrated in the example shown in
it can elicit a response when the smaller stimulus III no FIG 10-9.
202 Chapter 10 | Non-conventional perimetry

ILLUSTRATION OF THE PRINCIPLE OF USING STIMULUS V FOR LOW VISION PATIENTS

STIMULUS NORMAL ADVANCED PATHOLOGY

SAP stimulus III

0.43°

SAP stimulus V

1.7°

Receptive retinal
ganglion cells

Parvocellular Koniocellular Magnocellular

FIGURE 10-9 The standard Goldmann size III white stimulus is too small to reach sufficient cells to elicit a response in this
example (top). The larger Goldmann stimulus size V can still trigger cells, offering an increased dynamic testing range for
patients with severe vision loss.

In addition to the increased dynamic range, the larger and intense stimulus available (as illustrated in FIG 6-3), is also
thus more visible stimulus size V has also been shown to recommended. This approach saves valuable testing time
have signiicantly lower test-retest variability compared to and is easier for patients to complete. For more informa-
stimulus size III.19-22 This is thought to be due to a larger tion on the low-vision strategy, see Chapter 6.
stimulus being easier to see, which is essential in low-
vision patients who struggle much more with perimetric Because stimulus sizes III and V are not directly compa-
testing than patients with normal visual ields. rable, switching to stimulus V is only recommended for
patients for whom testing with stimulus III no longer
Besides using stimulus size V for low-vision patients, use renders useful clinical results, either due to the loor effect
of the low-vision strategy, which starts with the most or the large variability of stimulus III.
References 203

REFERENCES
1. Gonzalez de la Rosa M, Gonzalez-Hernandez M. Pulsar perimetry. A review and new results. Ophthalmologe.
2013;110:107-115.
2. Zeppieri M, Brusini P, Parisi L, Johnson CA, Sampaolesi R, Salvetat ML. Pulsar perimetry in the diagnosis of early
glaucoma. Am J Ophthalmol. 2010;149:102-112.
3. Hirasawa K, Takahashi N, Matsumura K, Kasahara M, Shoji N. Diagnostic capability of Pulsar perimetry in pre-perimetric
and early glaucoma. Sci Rep. 2017;doi:10.1038/s41598-017-03550-x.
4. van der Schoot J, Reus NJ, Colen TP, Lemij HG. The ability of short-wavelength automated perimetry to predict conversion
to glaucoma. Ophthalmology. 2010;117:30-34.
5. Sample PA, Medeiros FA, Racette L, et al. Identifying glaucomatous vision loss with visual-function-speciic perimetry in
the diagnostic innovations in glaucoma study. Invest Ophthalmol Vis Sci. 2006;47:3381-3389.
6. Gonzalez-Hernandez M, de la Rosa MG, de la Vega RR, Hernandez-Vidal A. Long-term luctuation of standard automatic
perimetry, pulsar perimetry and frequency-doubling technology in early glaucoma diagnosis. Ophthalmic Res.
2007;39:338-343.
7. Salvetat ML, Zeppieri M, Parisi L, Johnson CA, Sampaolesi R, Brusini P. Learning effect and test-retest variability of pulsar
perimetry. J Glaucoma. 2013;22:230-237.
8. Matsumoto C, Takada S, Okuyama S, Arimura E, Hashimoto S, Shimomura Y. Automated licker perimetry in glaucoma
using Octopus 311: a comparative study with the Humphrey Matrix. Acta Ophthalmol Scand. 2006;84:210-215.
9. Nomoto H, Matsumoto C, Takada S, et al. Detectability of glaucomatous changes using SAP, FDT, licker perimetry, and OCT.
J Glaucoma. 2009;18:165-171.
10. Rota-Bartelink A. The diagnostic value of automated licker threshold perimetry. Curr Opin Ophthalmol. 1999;10:
135-139.
11. Lachenmayr BJ, Gleissner M. Flicker perimetry resists retinal image degradation. Invest Ophthalmol Vis Sci.
1992;33:3539-3542.
12. Sample PA, Johnson CA, Haegerstrom-Portnoy G, Adams AJ. Optimum parameters for short-wavelength automated
perimetry. J Glaucoma. 1996;5:375-383.
13. Horn FK, Brenning A, Jünemann AG, Lausen B. Glaucoma detection with frequency doubling perimetry and short-
wavelength perimetry. J Glaucoma. 2007;16:363-371.
14. Johnson CA, Brandt JD, Khong AM, Adams AJ. Short-wavelength automated perimetry in low-, medium-, and high-
risk ocular hypertensive eyes. Initial baseline results. Arch Ophthalmol. 1995;113:70-76.
15. Delgado MF, Nguyen NT, Cox TA, et al. Automated perimetry: a report by the American Academy of Ophthalmology.
Ophthalmology. 2002;109:2362-2374.
16. Mojon DS, Zulauf M. Normal values of short-wavelength automated perimetry. Ophthalmologica. 2003;217:260-264.
17. Kwon YH, Park HJ, Jap A, Ugurlu S, Caprioli J. Test-retest variability of blue-on-yellow perimetry is greater than white-on-
white perimetry in normal subjects. Am J Ophthalmol. 1998;126:29-36.
18. Wall M, Woodward KR, Doyle CK, Zamba G. The effective dynamic ranges of standard automated perimetry sizes III and V
and motion and matrix perimetry. Arch Ophthalmol. 2010;128:570-576.
19. Wall M, Doyle CK, Eden T, Zamba KD, Johnson CA. Size threshold perimetry performs as well as conventional automated
perimetry with stimulus sizes III, V, and VI for glaucomatous loss. Invest Ophthalmol Vis Sci. 2013;54:3975-3983.
20. Wall M, Doyle CK, Zamba KD, Artes P, Johnson CA. The repeatability of mean defect with size III and size V standard
automated perimetry. Invest Ophthalmol Vis Sci. 2013;54:1345-1351.
21. Wall M, Woodward KR, Doyle CK, Artes PH. Repeatability of automated perimetry: a comparison between standard
automated perimetry with stimulus size III and V, matrix, and motion perimetry. Invest Ophthalmol Vis Sci. 2009;50:974-979.
22. Morgan AM, Mazzoli LS, Caixeta-Umbelino C, et al. Expediency of the Automated Perimetry Using the Goldmann V
Stimulus Size in Visually Impaired Patients with Glaucoma. Ophthalmol Ther. 2019;doi:10.1007/s40123-019-
0175-9.
 205

CHAPTER 11
KINETIC PERIMETRY

WHAT IS KINETIC PERIMETRY?

LIMITATIONS OF STATIC PERIMETRY
LOW SPATIAL RESOLUTION

Static perimetry is currently the most commonly used The major drawback of static perimetry is that the most
type of perimetry. With static perimetry, sensitivity common static test patterns have low spatial resolution.
thresholds are determined at a speciied number of test Because testing the entire visual ield with a densely
locations. These thresholds are then compared to the spaced test grid would be very time-consuming, only a
sensitivity thresholds of normal controls of the same representative sampling of potential visual ield locations
age as the patient. Small changes in sensitivity can be is tested. As a result, static perimetry provides very lim-
detected with high accuracy. Because this is essential ited information about small-sized scotomas such as the
for detecting glaucoma and monitoring its progression, blind spot, as shown in FIG 11-1. Additionally, deining the
static perimetry is well suited for glaucoma care and boundaries of scotomas can also be compromised by the
management. low spatial resolution of static perimetry.

LOW SPATIAL RESOLUTION WITH STATIC PERIMETRY

STATIC, 6° SPACING STATIC, 2° SPACING KINETIC

(30-2)

10 20 10 20 10 20

FIGURE 11-1 Static perimetry has relatively low spatial resolution as demonstrated in this example in which the blind spot is
tested. Using a 30-2 pattern with 6°spacing, only one or two locations are tested within the blind spot, providing no details
about its size. Using a customized test pattern with 2°spacing provides higher, but not optimal resolution, while increasing test
duration. Kinetic perimetry in this situation provides much higher spatial resolution with similar or lower test duration.
206 Chapter 11 | Kinetic perimetry

SLOW PERIPHERAL TESTING

Static perimetric testing is typically limited to the central FIG 5-13) or with widely spaced test grids such as in the
30° visual ield because this is the most crucial area of G-Periphery pattern (FIG 5-6) for glaucoma to save test
visual function and the region in which most early and time. More detailed full threshold tests like the 07 pat-
moderate glaucomatous scotomas occur. When static tern (FIG 5-11) require considerable test time and are too
perimetry is performed in the periphery, it is often used long for some patients to complete reliably. In addition,
in a qualitative way such as in legal documentation or vi- their accuracy is still limited due to the large extent of the
sual disability tests (e.g., visual ield driving examinations, peripheral visual ield as illustrated in FIG 11-2.

SLOW PERIPHERAL TESTING WITH STATIC PERIMETRY

STATIC STATIC
Q uantitative dynamic Q ualitative 2LT
strategy strategy KINETIC
12 12 12
07 pattern 07 pattern
9 3 9 3 9 3
6 6 6
+
+

+ +
+

+ + + +
+
+ + +
+ +
+
+ + + +
+
+ +
+ +
+ + + + + + + +

+ + +
10 20 30 40 50 60 70 80 90
+ + +
+
+
+ + +
+
+
+ + +
+
+
+
+ +
+
+ + +

+
+ +

+
+

FIGURE 11-2 Peripheral testing with static perimetry is time-consuming under both q uantitative and q ualitative strategies, as
this example of a postchiasmal lesion resulting in hemianopia with macular sparing demonstrates. Note that a k inetic test can
be up to three times faster than a q uantitative static test.
What is kinetic perimetry 207

DESCRIPTION OF KINETIC PERIMETRY

Kinetic perimetry is an alternative method to static that it is used to map a patient’s hill of vision in order
perimetry. Its major advantages are that it provides high- to identify regions of normal and abnormal sensitivity to
er spatial resolution, is faster for peripheral testing and light. However, the procedure used to achieve this goal is
involves greater interaction between the examiner and fundamentally different.
the patient. It has the same goal as static perimetry, in

MOVING STIMULI ALONG VECTORS

With kinetic perimetry, sensitivity thresholds are deter- visual ield location at which that response occurs has a
mined by moving stimuli of various sizes and light inten- sensitivity threshold equal to the speciic light intensity
sities from a region of non-seeing to a region of seeing. used along the vector. The process continues so that all
The trajectory of the stimulus is called a vector. regions of the visual ield are evaluated with this light
intensity and stimulus size. This procedure is then repeat-
As in static perimetry, the patient is asked to press the ed with stimuli of different intensities and size so that a
response button once the stimulus is seen. The speciic map of visual ield sensitivity can be generated (FIG 11-3).

ISOPTERS

When a suficiently large number of vectors are tested light intensity. In pathological situations this does not
throughout the visual ield with the same stimulus, the always apply because within the isopters there may be
response points of each vector can be connected to form smaller areas of non-seeing (scotomas) that will be dis-
a boundary of equal sensitivity. This boundary is called cussed in the next section. Several isopters can be drawn
an isopter and is comparable to the contour line on a by varying the size and intensity of the stimuli from more
topographical map. If a person has normal vision, then all visible (larger and more intense) to less visible (smaller
points inside the isopter are areas of seeing and all points and dimmer) targets.
outside the isopter are areas of non-seeing for a given

SCOTOMAS

Not all locations within a given isopter are areas of seeing. evaluations are called spot checks. Once located, radi-
There may also be areas of non-seeing (i.e., scotomas). al vectors can be drawn moving again from the area of
Using the analogy of the hill, these areas of non-seeing non-seeing (here the location of the center of the scoto-
are like lakes or local depressions on the hill of vision, ma) towards an area of seeing (i.e., outwards).
which are not identiiable using the procedure described
above. Instead, static points of the same intensity as the Using this approach and combining all isopters and
outer isopter already drawn have to be evaluated at differ- scotomas, the hill of vision can be drawn as illustrated
ent locations inside the isopter to locate scotomas. These in FIG 11-4.
208 Chapter 11 | Kinetic perimetry

KINETIC TESTING METHODOLOGY

Patient Do you see Threshold along first vector

response the stimulus?
Sensitivity
threshold

Fixation

Vector
(Stimulus trajectory)

Do you see Isopter

Patient the stimulus? (Thresholds of one stimulus type)
responses Sensitivity
threshold

Fixation

Vector
(Stimulus trajectory)

Do you see Hill of vision

Patient the stimulus? (Thresholds of several stimulus types)
responses
Sensitivity
Fixation threshold

Fixation

Vector
(Stimulus trajectory)

FIGURE 11-3 In k inetic perimetry, sensitivity thresholds are determined by moving a stimulus of fixed intensity and siz e along
a vector from an area of non-seeing to an area of seeing (top). In a normal visual field, the area of non-seeing to seeing is
typically in the direction from the periphery towards fixation. The hill of vision can be drawn by connecting several thresholds
of eq ual sensitivity (middle) thus forming an isopter and by drawing several isopters (bottom). An isopter can be thought of as
a contour line of the hill of vision.
What is kinetic perimetry 209

IDENTIFICATION OF LOCAL SCOTOMAS WITH KINETIC PERIMETRY

Patient Do you see Static points inside isopter

responses the stimulus? (Identification of areas of local depression)
Sensitivity
threshold

Fixation

= Seen
= Not seen

Static points

Do you see Isopter of local depression

Patient the stimulus? (Identification of boundaries of local depression)
responses Sensitivity
threshold

Fixation

= Seen
= Not seen

Vector
(Stimulus trajectory)

Do you see Hill of vision

Patient the stimulus? (Thresholds of several stimulus types
responses including local depressions)
Sensitivity
Fixation threshold

Fixation

Vector
(Stimulus trajectory)

FIGURE 11-4 Static points (spot check s) are used to identify areas of local depression. Once identified, radial vectors
originating from the location of the local depression allow drawing the isopter representing the boundary of the local
depression. The hill of vision can be drawn by connecting several thresholds of eq ual sensitivity thus forming an isopter and
by drawing several isopters.
210 Chapter 11 | Kinetic perimetry

HILL OF VISION AS A TOPOGRAPHICAL MAP

Sensitivity
threshold

Fixation
Fixation
Isopter 4
Isopter 3
Isopter 2
Isopter 1

FIGURE 11-5 Kinetic results are displayed similarly to a topographical map. Lines of eq ual stimulus intensity and siz e are
called isopters and are used to display the hill of vision in a two-dimensional map, similar to contour lines on a topographical
map. Localiz ed areas of non-seeing, such as that shown by the filled light blue circle, represent scotomas or areas of non-
seeing for that target.

THE HILL OF VISION AS A TOPOGRAPHICAL MAP

Kinetic results are displayed as a topographical map. the hill of vision largely depends on its expected shape
Similar to contour lines on a topographical map, isopters (i.e., the pattern of a speciic pathology). In addition to
are used to display the hill of vision with its outline, its the outline of the hill of vision, crevices, ridges and lo-
crevices, ridges and even local depressions as shown in cal depressions have to be identiied individually, and the
FIG 11-5. In this manner the three-dimensional hill of slope of sensitivity transitions should be noted. Because
vision can be represented in a two-dimensional drawing. of this, kinetic perimetry today is not fully automated and
requires an interaction between the examiner and the
The procedure used to create the topographical map of patient.

WHY PERFORM KINETIC PERIMETRY?

BENEFITS OF KINETIC PERIMETRY
In contrast to static perimetry, in which thresholds are
carefully determined at a number of pre-determined will be at threshold (scanning through a large area and
locations (assessing a wide range of light intensities to identifying a speciic location). This leads to a number of
determine thresholds at each location), kinetic perimetry very distinct advantages of kinetic perimetry over static
searches for the location at which a given light intensity perimetry.
Why perform kinetic perimetry? 211

STATIC VERSUS KINETIC PERIMETRY

STATIC
Dynamic strategy
12
07 pattern
12 KINETIC
9 3 9 3
6 6

10 20 30 40 50 60 70 80 90

FIGURE 11-6 A patient with a ring scotoma due to retinitis pigmentosa tested both with static (left) and k inetic (right)
perimetry. Note that k inetic perimetry provides a much higher spatial resolution that allows detection of even small defects.
Static perimetry, in contrast, provides much less information during eq ual testing time.

HIGH SPATIAL RESOLUTION

Kinetic perimetry is better at deining the pattern and present in quadrantanopia and hemianopia¹ or a con-
shape of visual ield loss than static perimetry, as illus- stricted visual ield in end-stage glaucoma.² It is also very
trated in FIG 11-6. Because the patient can report seeing beneicial if small scotomas need to be mapped reliably,
the stimulus at any location along the entire trajectory of such as the blind spot or a scotoma due to a retinal hem-
a vector, many possible response locations can be mapped orrhage.
with a small number of vectors and the sequence of
kinetic scanning can be different for each eye rather than However, while stimulus intensities may be varied, typ-
using the same test pattern for all tests. This is especially ically only a small number of light intensities are used,
beneicial if one is interested in identifying sharp-edged making it challenging to detect small threshold changes
scotomas or steep isopter boundaries such as the deicits throughout the hill of vision.

FAST PERIPHERAL TESTING

Kinetic perimetry is a very eficient method of evaluat- central visual field; thus kinetic perimetry has many
ing the periphery (beyond 30 degrees of eccentricity), advantages for these conditions.¹,²,⁴-⁶
because a large area can be covered in a relatively short
time due to the moving stimuli,³ as shown in FIG 11-6. Driving ability testing, legal blindness examinations or pto-
sis testing³,⁷ also require peripheral visual ield evaluation.
Several neurological and retinal diseases affect the pe- Thus, in some countries (e.g., Germany), kinetic perimetry
ripheral visual ield earlier or more signiicantly than the is a legally accepted method to perform these tests.
212 Chapter 11 | Kinetic perimetry

EASIER FOR PATIENTS

Kinetic perimetry is highly lexible and interactive, and factors, kinetic perimetry is often used for low vision
hence can be adjusted to the reliability and capabilities patients⁴,⁵ or patients who experience challenges in
of the patient. Additionally, a moving stimulus is easier performing perimetry, including children.⁹
to see than a non-moving stimulus.⁸ Because of these

LIMITATIONS OF KINETIC PERIMETRY

REQUIRES HIGH SKILL OF THE EXAMINER

Even though kinetic perimetry is highly versatile, one on the other hand, is a heuristic procedure that is highly
of its drawbacks is that it cannot be fully automated for interactive between the patient and the examiner. Every
all clinical situations, as the shape and height of an indi- stimulus manipulation by the examiner affects how the
vidual hill of vision depends on pathology. Thus, kinetic patient will respond, and these responses will in turn in-
perimetry requires much more interaction between the luence the next maneuver of the examiner. In this sense,
examiner and patient than static perimetry. kinetic perimetry is similar to chess in that it incorpo-
rates a lexible and adaptive strategy.
Conceptually, the difference between static and kinetic
perimetry is similar to the difference between checkers Being able to correctly map all possible clinical situations
and chess. Static perimetry uses a pattern of visual ield requires great skill. Depending on prior knowledge, it
locations (placed along either a Cartesian coordinate grid may take a training period of three months or more for
or a polar coordinate system) that are ixed for each test, the examiner to become fully familiar and comfortable
and uses the same strategy to determine the sensitivity with the test procedure in any situation. In this view, it
threshold for an increment of light on the uniform back- is a very challenging procedure to implement on an auto-
ground. It is similar to checkers in that the procedure is mated device. With a skilled and experienced examiner,
essentially the same for each eye tested, which limits the however, it is possible to obtain the highest quality infor-
amount of information one can obtain. Kinetic perimetry, mation concerning the peripheral visual ield.

VARIABILITY AMONG EXAMINERS

There is no consensus or standard method of conducting within one clinical center, the quality and eficiency of
kinetic perimetry, making it more challenging to com- kinetic perimetry can vary considerably from one exam-
pare results from one clinical center with the indings iner to the next.
from another than it is with static perimetry. And even
Why perform kinetic perimetry? 213

COMPARISON BETWEEN STATIC AND KINETIC PERIMETRY TABLE 11-1

STATIC KINETIC

LOCATIONS Fixed number of pre-determined Individually adjustable moving

locations targets

AUTOMATION Fully automated Semiautomated, needs

involvement of examiner

SPATIAL RESOLUTION Low High

ACCURACY OF VISUAL Higher Lower

SENSITIVITY THRESHOLDS

WHAT IT IS BEST AT Small changes in sensitivity Small changes in spatial extent

DETECTING (e.g., sharp-edged scotomas)

Changes in central 30° Changes in periphery

Remaining vision in advanced

disease

Defects in children

COMMON USES Glaucoma Neuro-ophthalmological conditions

Macular diseases Peripheral retinal diseases

Visual ability testing Low vision

Children

CHALLENGING IDENTIFICATION OF SMALL SENSITIVITY CHANGES AND DIFFUSE LOSS

While kinetic perimetry is better at identifying the pat- loss are more dificult to identify with kinetic perimetry.
terns and shapes of visual loss compared to static perime- A direct comparison between static and kinetic perimetry
try, small sensitivity changes²,⁶ and widespread or diffuse is provided in TABLE 11-1.
214 Chapter 11 | Kinetic perimetry

HOW TO PERFORM KINETIC PERIMETRY

THE GOLDMANN PERIMETER:
KINETIC VISUAL FIELD TESTING
Quantitative kinetic perimetry was developed in 1946 Because of the lexible and adaptive properties of kinet-
by Hans Goldmann and Haag-Streit¹⁰ and was the stan- ic perimetry, the manual Goldmann perimeter (FIG 11-7)
dard of visual ield testing prior to the invention of the is still widely used and remains the reference for kinetic
irst automated perimeter, the Octopus 201, in 1974.¹¹,¹² perimetry today.

THE GOLDMANN PERIMETER AND ITS SUCCESSOR, THE OCTOPUS 900

FIGURE 11-7 The Octopus perimeters (right) retain all the characteristics of the manual Goldmann perimeter (left).

To allow for continuity, the Octopus kinetic perimeter TABLE 11-2 summarizes the major differences and similar-
retains all the characteristics of the manual Goldmann ities between Octopus and Goldmann kinetic perimetries.
perimeter including the same lexible and adaptive prop-
erties. It has been shown to be fully comparable to a It is helpful to keep the legacy of manual Goldmann
manual Goldmann perimeter.13-17 In addition, it provides perimetry in mind because many deinitions and uses
standardized test conditions and semiautomation of ki- stem from the time when the Goldmann perimeter
netic perimetry to optimize clinical worklow and increase was invented, and they are easier to understand when
consistency of results among examiners and centers. one is familiar with the manual Goldmann perimeter.
How to perform kinetic perimetry 215

COMPARISON BETWEEN OCTOPUS KINETIC PERIMETRY AND GOLDMANN TABLE 11-2

KINETIC PERIMETRY

OCTOPUS KINETIC PERIMETRY GOLDMANN KINETIC PERIMETRY

METHODOLOGY Computer controlled stimulus Manual stimulus presentation

presentation

DESIGN Goldmann bowl (radius = 30cm) Goldmann bowl (radius = 30cm)

Background illumination 31.4 asb Background illumination 31.4 asb
(10 cd/m²) (10 cd/m²)

STIMULUS TYPES Goldmann sizes I to V Goldmann sizes 0 to V

Intensities 1a to 4e Intensities 1a to 4e

STIMULUS SPEED Fixed (1 – 10°/s) Manually guided

Manually guided

VECTOR TYPES Guided vector Straight

Free-hand vector Curvilinear
Static points Static points

INDIVIDUALIZATION & Full individualization Full individualization

AUTOMATION
Automation with added
individualization
Full automation

ADDITIONAL FEATURES Reaction time compensation

Normal isopter ranges

KEY DECISIONS IN KINETIC PERIMETRY

As with static perimetry, a number of key questions need • Which stimulus type should be used?
to be asked before starting a kinetic test and the answers • Which stimulus size?
will largely determine the results that one is able to • Which stimulus intensity?
achieve. These questions are similar to those asked for • Which stimulus speed?
static perimetry, but are answered differently. These • Which testing methodology should be used?
questions are: • What is the trajectory of the vector?
• Can some of the testing be automated?
216 Chapter 11 | Kinetic perimetry

STIMULUS TYPES
Similarly to the questions asked in static perimetry, the isopters and scotomas. Stimuli can be made more visible
irst question about stimulus type in kinetic perimetry by changing the stimulus size or intensity or by varying
has no clearly right or wrong answer. One can deine both together. For a normal visual ield, the most visible
standard testing methodologies for certain situations stimuli lead to the largest isopters and the least visible
and follow them through for each patient. stimuli lead to the smallest isopters. In FIG 11-8, common
stimuli are shown that allow a thorough assessment of
In order to scan a patient’s entire hill of vision, one needs the full visual ield.
more and less visible stimuli to be able to identify different

NORMAL ISOPTERS FOR DIFFERENT STIMULUS TYPES

120 105 90 75 60
135 45

150
V4e
30
III4e
165 I4e 15
I2e
I1e
180 10 30 40 50 60 70 80 90 0

195 345

210 330

225 315

240 255 270 285 300

FIGURE 11-8 By using stimuli of different siz e and intensity, the hill of vision of a person with normal vision can be drawn. The
III4e stimulus is larger and more intense and leads to a larger isopter than the smaller and dimmer I1e stimulus.

STIMULUS SIZE

Octopus kinetic perimetry uses ive distinct stimulus siz- larger stimuli III to V are detected outside of the central
es, Goldmann I to V, with Goldmann I being the smallest visual ield in people with normal vision. Goldmann size
and each subsequent size being four times larger in area I is also often used to map small or shallow scotomas
than the previous one as shown in TABLE 11-3. The sizes that require high spatial resolution (e.g., the blind spot).
and naming scheme stem from the convention used by Although size 0 is available on the Goldmann perimeter,
the manual Goldmann perimeter and were kept exactly it has not been included on the Octopus perimeter. This
the same to provide direct continuity. is because the size 0 stimulus is dificult to perceive
through the optics of the eye, which can lead to unre-
While there is no standardized procedure for kinetic liable and artefactual test results. The size 0 stimulus
perimetry, and stimulus selection depends on the exam- also has a limited dynamic range.
iner and the patient, Goldmann sizes I to V at the highest
intensity are commonly used to test the far and inter- Goldmann V is the largest and most visible stimulus and is
mediate peripheral visual ield. Goldmann sizes I and II often used for low vision patients who cannot see smaller
combined with lower intensities are then used for the stimuli.
highly sensitive central area because the isopters of the
How to perform kinetic perimetry 217

GOLDMANN STIMULUS SIZES I TO V TABLE 11-3

SIZE DIAMETER AREA [MM2] RECOMMENDED FOR

V 64 Low vision (end stage disease)

Far periphery (determination of anatomical
visual ield borders)

1.7°

IV 16

0.8°

III 4 Periphery
Standard for static testing
0.43°

II 1
0.2°

I 0.25 Peripheral and central testing

0.1° Small area and high resolution (e.g., blind
spot, small or shallow scotomas)

STIMULUS INTENSITY

Stimulus intensities in Octopus kinetic perimetry range for stimulus intensity stems from the manual Goldmann
from 1a to 4e, with 1a being the dimmest and 4e being perimeter (BOX 11A). Because this scale is the accepted
the brightest. A total of 20 distinct stimulus intensities are standard in kinetic perimetry, it is also incorporated
available, as shown in FIG 11-9. The naming convention into Octopus kinetic perimetry.

STIMULUS INTENSITIES IN KINETIC PERIMETRY

1a: Darkest stimulus 4e: Brightest stimulus

19 dB 0 dB

1 2 3 4

a b c d e a b c d e a b c d e a b c d e

FIGURE 11-9 The intensities of the Goldmann stimuli used in kinetic perimetry are presented in 1 dB steps from the darkest 1a
to the brightest 4e intensity.
218 Chapter 11 | Kinetic perimetry

As a rule, higher intensity stimuli such as the 4e are used dB) are usually chosen. When mapping absolute defects
for peripheral testing and dimmer stimuli such as the 1e (i.e., areas of blindness), none of the stimuli are visible to
are used for central testing. Using stimuli with very simi- the patient. Then, the brightest 4e stimulus can be select-
lar intensities adds little diagnostic information because ed, as it is the easiest for the patient to see and possibly
their isopters are very close to each other and would respond to at the borders of the defect. When there is a
clutter the picture and represent a generally poor trade- wide separation between contour lines (isopters or sco-
off between test duration and information gained. Thus, tomas), intermediate stimulus intensities can be selected
stimuli with several dB differences in intensity (3 to 5 to test the region between the isopters.

BOX 11A THE ORIGIN OF THE STIMULUS INTENSITY SCALE

The manual Goldmann perimeter only contains one bright light source. In order to generate dimmer
stimuli, ilters are placed in front of the light source, making the stimulus dimmer.
There are two sets of ilters. Filters a, b, c, d and e dim the stimulus by 1 dB, and ilters 1, 2, 3 and 4 dim
it by 5 dB. In combination, 20 different stimuli can be produced, with the brightest, 4e, representing a
maximum stimulus brightness of 1,000 asb (315 cd/m²).

STIMULUS SPEED

Each stimulus for Octopus kinetic perimetry moves As a rule, stimulus velocities of 3 – 5°/s have been shown
at a constant speed to allow for reproducible results. to optimize the trade-offs among accuracy, reliability and
The stimulus speed should be selected to optimize the eficiency13,18 and are recommended as a standard set-
trade-off between accuracy and test duration. While the ting. For small scotomas such as the blind spot, slower
inluence of patient reaction time is smaller for a slower stimuli of 2 – 3°/s are recommended as the clinically rel-
stimulus, the longer testing time can result in fatigue. In evant spatial changes are small and are more accurately
such cases, using a stimulus that moves faster leads to mapped with a slower stimulus.
more reproducible results.

GENERAL TESTING METHODOLOGIES

Finding the adequate testing methodology for any pa- struction and advice from a colleague highly experienced
tient is a process that requires an experienced examiner in performing this procedure is highly recommended.
who can adapt to the patient’s responses. Consulting a
textbook focusing speciically on kinetic perimetry19-21 is The next sections will illustrate key concepts of kinetic
recommended for guidance. In addition, obtaining in- perimetry as a starting point for beginners, but are insufi-
cient to attain high proiciency in kinetic perimetry.
How to perform kinetic perimetry 219

IDENTIFICATION OF NORMAL ISOPTER LOCATION AND SHAPE

For each stimulus size and intensity, Octopus kinetic pe- to age-matched normative data will allow correct in-
rimetry automatically provides the age-matched normal terpretation of the results. As the hill of vision is rather
isopter location as a reference. The inner dark central steep towards the far periphery, large age-related sen-
band represents 25–75% of age-matched normals; the sitivity changes have only a small inluence on isopter
outer light band denotes 5–95% of age-matched healthy location.21-23
normals, as shown in FIG 11-10.
In practical terms, the normal isopter location provides
These zones support at-a-glance identiication of devia- guidance on where to start placing vectors. Placing vec-
tions from normal and are especially helpful in interpret- tors far outside of a normal isopter would only waste
ing central visual ield defects and generalized diffuse or time, as the patient cannot see the stimuli in these areas.
widespread loss. As the hill of vision is rather lat from Conversely, starting too near the anticipated location of
the mid-periphery to the macula, those isopter locations detection can make the patient unprepared to respond
are signiicantly inluenced by age and only comparison and can produce untrustworthy results.

NORMAL ISOPTERS
120 105 90 75 60
135 45
5 – 95% 25 – 75%
150 330

165 1
15

180 10 00
30 40 50 60 70 80 90

195 345
45

210 330
30

225 315

240 255 270 285 300

FIGURE 11-10 The normal isopters provide guidance on where to start a vector of a given intensity. They also serve as a guide
in judging whether an isopter is normal. The dark red band represents 25–75% of healthy normals; the outer light red band
represents 5–95% of healthy normals of the same age. Note that the isopters are not round, but egg-shaped. They extend
farthest in the inferior temporal visual field and least in the superior nasal visual field.
220 Chapter 11 | Kinetic perimetry

MAPPING THE OUTLINE OF THE HILL OF VISION

The overall outline of the hill of vision provides valuable affected area of the visual ield. As a general rule, stimuli
information about a patient’s visual ield because devi- should not move directly along the horizontal or vertical
ations from normal isopter shapes indicate abnormal meridians, because inconsistent results will be obtained.
visual fields. Thus, mapping the outline of the hill of This is because the boundaries of quadrantanopia and
vision is usually the irst step in kinetic perimetric testing. hemianopia are typically positioned along the horizon-
To map the outline of the hill of vision, stimuli are moved tal and vertical meridians and a stimulus moving along
from the peripheral end of the normal band towards the these meridians cannot map them clearly. Glaucomatous
center (ixation) along a given radial meridian. By repeating deicits along the nasal horizontal meridian (e.g,. nasal
this procedure with different stimulus types, the outline steps and arcuate scotomas) represent another example
of the hill of vision can be drawn in detail, as shown in where the stimulus should not be moved along the hor-
FIG 11-11. izontal meridian. Thus, for these conditions, the radial
vectors are best placed with an offset of a few degrees and
This procedure is a fast and easy way to identify quadran- possibly parallel to the horizontal and vertical meridians.
tanopia and hemianopia, as the isopter will dip in the

MAPPING THE OUTLINE OF THE HILL OF VISION

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

FIGURE 11-11 Superior-nasal q uadrantanopia identified with radial vectors along meridians. Note that the vectors along the
horiz ontal and vertical midlines are placed parallel to them to allow for better detection of the boundaries of the visual loss in
that q uadrant. There are no responses in the superior nasal q uadrant of this right eye, indicating the q uadrantanopia.

DETAILING THE BOUNDARIES OF AN ISOPTER

As with any contour or topographic map, the hill of vision which either manifests as inconsistent with adjacent vec-
may have crevices or depressions, which represent tors or outside of the expected normal sensitivity, which
relative or absolute scotomas. As shown in FIG 11-11, these requires further investigation.
defects may not be identiied with standard vectors moving
from the periphery to the center. This is where custom- Conceptually, the process is always the same. When
ized individual assessment is needed. The examiner has alerted to a potential abnormal isopter shape, the operator
to identify where there is a lack of normal response, should estimate where the isopter is likely to be. To verify
How to perform kinetic perimetry 221

that this isopter is correct, additional vectors are drawn to confirm that it is outside of the normal expected
perpendicular to the anticipated boundary of the isopter, responses.
as shown in FIG 11-12. The perpendicular vectors optimize
the likelihood that the hill of vision will be met “head-on”, If the patient response is as expected on the imagined
which will reduce variability and provide more clinically isopter, the isopter shape is conirmed and can be drawn.
meaningful information. Before initiating this process, it If not, the procedure has to be repeated, taking into account
is important to recheck the abnormal isopter shape the new information until the isopter location is conirmed.

DETAILING THE BOUNDARIES OF AN ISOPTER

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

FIGURE 11-12 Procedure for detailing the boundaries of abnormal isopters on a superior-nasal quadrantanopia. The lack
of normal responses allows the examiner to estimate the location of the isopter (dotted gray line), and then test using
perpendicular vectors (bold red) crossing that line to confirm the shape of the true isopter.

IDENTIFICATION OF ISOLATED SCOTOMAS

While the procedure shown in FIG 11-12 allows identii- possible areas of sensitivity loss (areas of non-seeing or
cation of the outline of the hill of vision, it usually misses scotomas). This allows for quick identiication of scoto-
isolated absolute defects or local depressions located in- mas as shown in FIG 11-13.
side of an isopter or between isopters. In keeping with
the analogy of a hill, isolated defects can be thought of as If areas of defects are identiied, their boundaries can be
lakes or depressions of different shapes and depths. In mapped by moving radial stimuli from inside of the de-
order to identify these defects, spot-checking inside the fects from the center towards its edges. This procedure
hill of vision must be performed. Spot-checking quickly can be repeated with stimuli of different visibility to
examines locations between isopters using static points deine the slope and depth of the defect.
of the same size and intensity as the outer isopter, to ind
222 Chapter 11 | Kinetic perimetry

IDENTIFICATION OF ISOLATED SCOTOMAS

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 Defect
345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 Defect

345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

FIGURE 11-13 By placing a static point of the same intensity inside of an isopter or between isopters (spot check ing, red
circles), one can identify local defects that would otherwise be missed (no response, gray circle). Using radial vectors (bold
red lines) from the center of the area of non-seeing (from the inside) to the area of seeing (to the outside) allows drawing the
boundaries (gray bold line) of the defect in detail. For ease of reading, the defect should be filled with the appropriate color.

MAPPING THE HILL OF VISION USING SEVERAL STIMULUS TYPES

By repeating the procedures described in the previous identifying an unnatural isopter shape without having to
sections using different stimulus types with different sizes use extra vectors.
and intensities, several isopters can be drawn to charac-
terize the patient’s entire hill of vision. There are many When spot checking to identify local areas of depres-
tips and tricks to make this procedure eficient. A few of sion, the size and intensity of the outer isopter should
them are presented here. be used between the outer and the inner isopters (FIG 11-
14). Then, only the size and intensity of the inner isopter
When drawing a second isopter, placing the vectors of the should be used farther towards the center.
second isopter with a radial offset to the ones used in the
irst isopter is recommended, as seen in FIG 11-14. In other It is also important to remember that there may be more
words, the vectors used to determine the second isopter than one isopter for the same stimulus size and intensity.
should be placed at different locations than those used to There may be a region of detecting the target in the far
determine the irst isopter. This increases the chance of periphery, with an area of non-seeing closer to ixation,
How to perform kinetic perimetry 223

followed by a second area that can detect the target. This the visual pathways. Because of this, it is important to
can occur in some cases of retinal disease, moderate to make good use of spot checking and evaluate the entire
advanced glaucoma, and neurologic disorders affecting visual ield.

PLACEMENT OF VECTORS AND STATIC POINTS USING DIFFERENT STIMULUS TYPES

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

III4e III4e
I2e I2e

FIGURE 11-14 Vectors of different stimulus sizes and intensities are best placed with an offset to increase the chance of
identification of abnormal isopter shapes. When placing static points between two isopters, always use the intensity of the
more visible outer isopter.

Local scotomas can be absolute defects with sharp-edged FIG 11-15. For easy interpretation, these local depressions
boundaries such as the blind spot or relative defects with are typically illed with color to indicate that the corre-
a gentle slope on the edge of the defect as in glaucoma. To sponding stimulus cannot be seen within that visual ield
distinguish between the two, more than one stimulus is area.
needed to characterize a local scotoma as can be seen in

DISTINCTION BETWEEN ABSOLUTE AND RELATIVE SCOTOMAS

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

III4e
I2e

FIGURE 11-15 More than one isopter is needed to distinguish between absolute and relative scotomas. This example shows a
nasal step for a glaucoma patient.
224 Chapter 11 | Kinetic perimetry

CHECKING FOR VISUAL FIELD RELIABILITY

Like static visual ield testing, kinetic perimetry has a certain vectors to check for consistency of responses,
patient-related subjective component and the reliability as shown in FIG 11-16. To do this, two vectors should be
of the results largely depends on good patient coopera- placed as close together as possible (or repeated) and
tion and minimizing variability due to learning or fatigue then compared for consistency. If the responses are
effects.22,24,25 Therefore, it is also essential to check reliable, the two patient responses should be very close
for patient reliability in kinetic perimetry. While static pe- together, as shown in the igure below to the left which
rimetry uses global indices such as false positive and false means there is low test-retest variability. If they are sep-
negative catch trials and short-term luctuation, kinetic arated, as in the example below to the right, it indicates
perimetry employs other methodologies to test for similar an unreliable result with high test-retest variability. This
reliability indicators. procedure provides a good indicator for the quality of
the results. Similarly, spot checking can be repeated at
To assess short-term luctuation, it is worth duplicating various locations to assess response consistency.

CHECKING FOR SHORT-TERM FLUCTUATION

LOW SHORT-TERM FLUCTUATION HIGH SHORT-TERM FLUCTUATION

The two gray dots on each vector The two gray dots on each vector
are close to each other are far from each other

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

FIGURE 11-16 By repeating some vectors, short-term fluctuation and thus test-retest variability can be assessed. If the
responses are close together (left), it indicates good patient cooperation, good repeatability and high reliability. If the responses
largely differ (right), it indicates an unreliable visual field.

In legal driving and blindness examinations performed positive and false negative answers even though the pro-
with kinetic perimetry, it is worth checking for false an- cedure is different. Checking for false positive answers
swers to identify patients who may simulate responses can be easily done by presenting stimuli outside of the
or a lack of response (functional changes or visual mea- normal isopter area (FIG 11-17). By deinition, the patient
sures that are non-physiologic and non-pathologic). This is not supposed to see these stimuli. If there are many
can produce visual ield results that are either better or positive responses, this is a strong indicator of a patient
worse than the actual visual ield sensitivity proile. As who is malingering.
in static perimetry, it is possible to check for both false
How to perform kinetic perimetry 225

CHECKING FOR FALSE POSITIVES

NO FALSE POSITIVES FALSE POSITIVES

No response to stimuli 3 responses to stimuli
outside normal isopter outside normal isopter

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

FIGURE 11-17 Checking for false positive responses can be done by placing vectors or static points outside of a normal
isopter. If a patient responds, then these are false positives, as the patient cannot see them.

To detect false negative answers one places a more intense the patient to observe (FIG 11-18). Failure to see a more
or larger stimulus at a location where the stimulus was intense or larger stimulus than the one that was detected
previously detected. This stimulus should be easy for at threshold is considered to be a false negative response.

CHECKING FOR FALSE NEGATIVES

NO FALSE NEGATIVES FALSE NEGATIVES

Immediate response to larger or more intense Random response to larger or more intense
stimulus at a location previously seen stimulus at a location previously seen
120 105 90 75 60 120 105 90 75 60
135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345
Larger or more 195 345
Larger or more
intense stimulus intense stimulus
210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

Smaller or less Smaller or less

intense stimulus intense stimulus

FIGURE 11-18 Checking for false negative responses can be done by placing larger or more intense vectors or static points at
a location where a smaller or less intense stimulus was previously detected. If a patient does not respond, then these are false
negatives, as the patient should be able to see them.
226 Chapter 11 | Kinetic perimetry

PATIENT REACTION TIME COMPENSATION

Patient reaction time inluences the size of an isopter as For this reason, Octopus kinetic perimetry offers the
the patient’s response is produced some time after the possibility of adjusting for patient reaction time by mea-
stimulus is actually seen.22,23,26 This also adds signiicant suring its magnitude in the patient’s intact visual ield
variability to the test procedure.24 If a patient’s re- and applying a reaction time correction for it, as illus-
sponses were always instantaneous, outlines of the hill trated in FIG 11-19. In order to do so, the examiner should
of vision would be larger and isolated defects would be choose a reaction time vector of the same stimulus type
smaller than they appear on the printout. This makes as the isopter and place it into the patient’s seeing area. The
the interpretation of results challenging, especially in pa- patient should be able to see the stimulus immediately
tients with long or inconsistent reaction times. as it is presented. Thus, the time between stimulus pre-
sentation and when the patient presses the response
button represents the patient’s reaction time.

PATIENT REACTION TIME COMPENSATION

Reaction time
(RT) vector

Patient sees Patient responds

Standard vector

Standard vector with

RT compensation
0 ms 523 ms

FIGURE 11-19 There is always a lag between the moment the patient sees a stimulus and the moment a patient presses the
response button. This constitutes the patient’s reaction time. By placing reaction time (RT) vectors into the patient’s seeing
area, one can account for this lag.

For a precise measurement of patient reaction time, us- placing the reaction time vectors close to the correspond-
ing the average reaction time obtained from two or three ing isopter. FIG 11-20 provides an example of the clinical
different vectors for each stimulus type is recommended, usefulness of reaction time compensation.
How to perform kinetic perimetry 227

EXAMPLE OF THE CLINICAL USEFULNESS OF REACTION TIME COMPENSATION

REACTION-TIME REACTION-TIME
compensation compensation
turned OFF turned ON

Reaction time vectors

10 30 40 50 60 70 80 10 30 40 50 60 70 80

FIGURE 11-20 Without reaction time compensation, local depressions look uncharacteristically large (left). By using reaction
time vectors (bold red, double arrows) to determine the patient’s reaction time and by turning reaction time compensation on
(right), the patient’s adjusted defect size is revealed.

STEP-BY-STEP EXAMPLE OF KINETIC PERIMETRY

A real-life example of a complete kinetic test as performed in clinical practices is provided in FIG 11-21.

STEP-BY-STEP EXAMPLE OF A KINETIC TEST WITH SEVERAL ISOPTERS (STEPS 1-2)

1. Mapping outline of hill of vision 2. Detailing boundaries of isopter

I4e, 5°/s I4e, 5°/s

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

FIGURE 11-21 This example above shows a full kinetic perimetric test of a quadrantanopia with 4 isopters (shown here in
blue, red, gray and green), static points and reaction time compensation. Checks for consistent results and false positives are
not shown in this example.
228 Chapter 11 | Kinetic perimetry

STEP-BY-STEP EXAMPLE OF A KINETIC TEST WITH SEVERAL ISOPTERS (STEPS 3-8)

3. Drawing isopter 4. Mapping the next outline of hill of

I4e, 5°/s vision & detailing boundaries of isopter
in abnormal response region
V4e, 5°/s
120 105 90 75 60 120 105 90 75 60
135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

5. Drawing isopter 6. Spot-checking between isopters

V4e, 5°/s Use stimulus type from outer isopter
V4e, 0°/s

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

7. Mapping the next outline of hill of 8. Drawing isopter

vision & detailing boundaries of isopter I2e, 5°/s
I2e, 5°/s

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300
How to perform kinetic perimetry 229

STEP-BY-STEP EXAMPLE OF A KINETIC TEST WITH SEVERAL ISOPTERS (STEPS 9-14)

9. Spot-checking between isopters 10. Mapping the next outline of hill of vision
Use stimulus type from outer isopter & detailing boundaries & drawing isopter
I4e, 0°/s I1e, 2°/s

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

11. Spot-checking between isopters 12. Mapping of isolated defect

Use stimulus type from outer isopter (blind spot)
I2e, 0°/s, I1e, 0°/s I4e, 2°/s

120 105 90 75 60 120 105 90 75 60

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

13. Draw reaction time vectors 14. Reaction-time compensation

in visible area RT on
RT vectors, same intensity, size
and speed as respective standard vector
120 105 90 75 60 120 105 90 75 60
135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300
230 Chapter 11 | Kinetic perimetry

AUTOMATION OF KINETIC PERIMETRY

MANUAL KINETIC PERIMETRY – FULL FLEXIBILITY

In manual kinetic perimetry, the operator draws each uation. A drawback of manual kinetic perimetry is the
vector individually for each patient. This procedure, lack of consensus for a standard way to conduct it. As a
which is used on manual Goldmann perimeters, is fully result, there is limited comparability between the results
implemented on the Octopus perimeters. Therefore, a obtained from different examiners and clinics. Another
Goldmann manual perimetric test can be performed on drawback is that manual kinetic perimetry requires
the Octopus perimeter. The example presented above intensive training and there is a certain operator bias.
illustrates the lexibility of manual kinetic perimetry. Simpler procedures are therefore desirable for more
consistent and effective clinical worklows.
Manual kinetic perimetry is still widely used today be-
cause it allows full lexibility to adapt to any patient sit-

AUTOMATED KINETIC PERIMETRY– STANDARDIZATION

While kinetic perimetry testing often needs to be individ- responses are already known. An example is visual ield
ualized, there are certain indications where the expected testing for ptosis, as illustrated in FIG 11-22.

EXAMPLE OF FULLY AUTOMATED KINETIC PERIMETRY TO TEST FOR PTOSIS

PTOSIS TEMPLATE PTOSIS TEST

Full automation possible Test performed twice
with taped and untaped lid

120 105 90 75 60 120 105 90 75 60 Taped

135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 0 90 0
0 60 70 80

Untaped
195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

FIGURE 11-22 In ptosis testing, one is trying to identify the exact position of the lid, which always curves upwards from
the nasal to temporal side. Therefore, a standardized testing procedure of a few vertical vectors is all that is needed and a
very visible and adequately fast III4e to V4e at 3–5°/s is a good stimulus choice. This procedure can be fully automated and
performed both on taped and untaped lids.
How to perform kinetic perimetry 231

For any such indication with a clearly known defect pat- Full automation not only standardizes kinetic testing and
tern, Octopus kinetic perimetry allows storage of fully makes it much more comparable across examiners and
automated templates that can, once programmed, be clinics, it also makes the procedure as easy to learn and
run in the same way as Standard Automated Perimetry perform as static perimetry. As there is currently no con-
by simply pressing the start button. Only the isopters sensus on how a certain indication should be tested, each
remain to be drawn manually. clinic can deine the automated templates according to
its current testing methodologies.

SEMIAUTOMATED KINETIC PERIMETRY – STANDARDIZATION AND FULL FLEXIBILITY

Semiautomated kinetic perimetry offers the beneits of mode. In contrast to automated kinetic perimetry, vec-
both automated and manual kinetic perimetry with much tors can be individually added, but responses can also be
less of their respective shortcomings, and is a part of Octo- repeated or deleted if the examiner deems it necessary.
pus kinetic perimetry. Because of the full lexibility offered by semiautomated
kinetic perimetry, it can provide results that are as pre-
In semiautomated kinetic perimetry, the examination is cise as manual kinetic perimetry while greatly improving
started using a given predeined template in an automated the standardization within a clinic, as all examiners use

EXAMPLE OF CUSTOMIZED TEMPLATES FOR NEURO-OPHTHALMIC CONDITIONS

GENERAL ASSESSMENT PITUITARY ADENOMA

120 105 90 75 60 120 105 90 75 60
135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

HEMIANOPIA BLIND SPOT

120 105 90 75 60 120 105 90 75 60
135 45 135 45

150 30 150 30

165 15 165 15

180 10 30 40 50 60 70 80 90 0 180 10 30 40 50 60 70 80 90 0

195 345 195 345

210 330 210 330

225 315 225 315

240 255 270 285 300 240 255 270 285 300

FIGURE 11-23 Kinetic templates allow testing standardization, as the same methodology is always used. Full flexibility of adap-
tation to a patient’s specific situation is also enabled. Above are four examples of templates regularly used in a neuro-ophthalmic
clinic.25-27 For simplicity, only one stimulus type is displayed, but templates with more than one stimulus type are also possible.
232 Chapter 11 | Kinetic perimetry

the same underlying technique and only make adapta- needs. FIG 11-23 shows a number of templates that can be
tions if the patient requires it. This greatly improves used in a neuro-ophthalmic clinic. These templates are not
consistency among examiners and facilitates clinical considered the only possible templates for such condi-
result interpretation. tions, but rather examples of performing effective kinetic
perimetry in these situations.
Many different templates can be created for the most
commonly occurring indications, based on each clinic’s
References 233

REFERENCES
1. Rowe FJ, Noonan C, Manuel M. Comparison of Octopus semi-automated kinetic perimetry and Humphrey peripheral static
perimetry in neuro-ophthalmic cases. ISRN Ophthalmol. 2013;doi: 10.1155/2013/753202.
2. Scheuerle AF, Schiefer U, Rohrschneider K. Functional diagnostic options for advanced and end stage glaucoma.
Ophthalmologe. 2012;109: 337-344.
3. Alniemi ST, Pang NK, Woog JJ, Bradley EA. Comparison of automated and manual perimetry in patients with blepharoptosis.
Ophthal Plast Reconstr Surg. 2013;29:361-363.
4. Nowomiejska K, Brzozowska A, Koss MJ, et al. Quantiication of the visual ield loss in retinitis pigmentosa using semi-
automated kinetic perimetry. Curr Eye Res. 2016;doi: 10.3109/02713683.2015.1079328.
5. Nowomiejska K, Wrobel-Dudzinska D, Ksiazek K, et al. Semi-automated kinetic perimetry provides additional information to static
automated perimetry in the assessment of the remaining visual ield in end-stage glaucoma. Ophthalmic Physiol Opt. 2015;35:147-154.
6. Agarwal HC, Gulati V, Sihota R. Visual ield assessment in glaucoma: comparative evaluation of manual kinetic Goldmann
perimetry and automated static perimetry. Indian J Ophthalmol. 2000;48:301-306.
7. Riemann CD, Hanson S, Foster JA. A comparison of manual kinetic and automated static perimetry in obtaining ptosis
ields. Arch Ophthalmol. 2000;118:65-69.
8. Nevalainen J, Paetzold J, Krapp E, Vonthein R, Johnson CA, Schiefer U. The use of semi-automated kinetic perimetry (SKP)
to monitor advanced glaucomatous visual ield loss. Graefes Arch Clin Exp Ophthalmol. 2008;246:1331-1339.
9. Patel DE, Cumberland PM, Walters BC, Russell-Eggitt I, Rahi JS, OPTIC study group. Study of Optimal Perimetric Testing in Children
(OPTIC): Feasibility, Reliability and Repeatability of Perimetry in Children. PLoS One. 2015; doi: 10.1371/journal.pone.0130895.
10. Haag-Streit AG, (Hrsg.). 1858 - 2008: 150 Jahre Haag-Streit/150 Years of Haag-Streit. Bern: Stämpli Publikationen AG; 2008.
11. Johnson CA, Wall M, Thompson HS. A history of perimetry and visual ield testing. Optom Vis Sci. 2011;88:E8-15.
12. Fankhauser F. Remembrance of Hans Goldmann, 1899-1991. Surv Ophthalmol. 1992;37:137-142.
13. Rowe FJ, Rowlands A. Comparison of diagnostic accuracy between Octopus 900 and Goldmann kinetic visual ields.
Biomed Res Int. 2014;doi: 10.1155/2014/214829.
14. Nowomiejska K, Vonthein R, Paetzold J, Zagorski Z, Kardon R, Schiefer U. Comparison between semiautomated kinetic perimetry and
conventional Goldmann manual kinetic perimetry in advanced visual ield loss. Ophthalmology. 2005;112:1343-1354.
15. Ramirez AM, Chaya CJ, Gordon LK, Giaconi JA. A comparison of semiautomated versus manual Goldmann kinetic
perimetry in patients with visually signiicant glaucoma. J Glaucoma. 2008;17:111-117.
16. Rowe FJ, Hanif S. Uniocular and binocular ields of rotation measures: Octopus versus Goldmann. Graefes Arch Clini Exp
Ophthalmol. 2011;249:909-919.
17. Hashimoto S, Matsumoto C, Eura M, Okuyama S, Shimomura Y. Evaluation of kinetic programs in various automated
perimeters. Jpn J Ophthalmol. 2017;61:299-306.
18. Johnson CA, Keltner JL. Optimal rates of movement for kinetic perimetry. Arch Ophthalmol. 1987;105:73-75.
19. Anderson DR. Testing the ield of vision. St.Louis: CV Mosby; 1982.
20. Anderson DR. Perimetry - With and without automation. 2nd ed. St.Louis: CV Mosby; 1987.
21. Walsh TJ. Visual Fields: Examination and interpretation. 3rd ed. American Academy of Ophthalmology Monograph Series;
Oxford University Press; 2010.
22. Nowomiejska K, Brzozowska A, Zarnowski T, Rejdak R, Weleber RG, Schiefer U. Variability in isopter position and fatigue
during semi-automated kinetic perimetry. Ophthalmologica. 2012;227:166-172.
23. Grobbel J, Dietzsch J, Johnson CA, et al. Normal values for the full visual ield, corrected for age- and reaction time, using
semiautomated kinetic testing on the Octopus 900 perimeter. Transl Vis Sci Technol. 2016;5:doi:10.1167/tvst.5.2.5.
24. Hirasawa K, Shoji N. Learning effect and repeatability of automated kinetic perimetry in healthy participants. Curr Eye Res.
2014;39:928-937.
25. Rowe FJ, Sarkies NJ. Assessment of visual function in idiopathic intracranial hypertension: a prospective study. Eye
(Lond). 1998;12:111-118.
26. Rowe FJ, Cheyne CP, García-Fiñana M, et al. Detection of visual ield loss in pituitary disease: Peripheral kinetic versus
central static. Neuro-Ophthalmology. 2015;39:116-124.
27. Rowe FJ, Wright D, Brand D, et al. A prospective proile of visual ield loss following stroke: prevalence, type,
rehabilitation, and outcome. Biomed Res Int. 2013; doi: 10.1155/2013/719096.
 235

CHAPTER 12
TRANSITIONING TO A DIFFERENT
PERIMETER MODEL

INTRODUCTION
At the end of the life span of a perimeter or in order to are obtained on different perimeter models is irst pre-
beneit from technologies only available on a different sented. Then, this chapter highlights that while sensi-
perimeter model or brand, transitioning to a new perimeter tivity thresholds are not directly comparable between
with distinct characteristics may be necessary. Due to different models, sensitivity losses (i.e., deviations from
differences in the design and test parameters between normal sensitivity thresholds) are comparable to a large
perimeter models, the measured sensitivity thresholds extent because of the use of device-speciic normative
are not directly comparable. As a result, the variability databases. This chapter also provides practical guidance
introduced by a transition must be acknowledged and on how to minimize patient-related luctuation that may
addressed. arise during the transition and subside as patients become
familiar with the new device.
Octopus perimeters offer several features that make
it possible to transition smoothly between perimeter In addition, when transitioning from an HFA to an Octopus
models, regardless of whether the transition is from perimeter, it is important to recognize that each perimeter
one Octopus model to another Octopus model or from a uses its own, sometimes proprietary, test parameters
Humphrey Field Analyzer (HFA) to any Octopus model. and result displays. As a result, the transition may appear
These features minimize, to a large extent, the impact of challenging. Practical recommendations for the selection
the different parameters used in the various perimeter of test patterns and strategies are presented to facilitate
models and are systematically presented in this chapter. the transition. Furthermore, information is provided on
how to interpret the perimetric result after the transition
An explanation of why different sensitivity thresholds from an HFA to an Octopus perimeter.
236 Chapter 12 | Transitioning to a different perimeter model

GENERAL ASPECTS OF TRANSITIONING

MEASURED SENSITIVITY THRESHOLDS CANNOT BE
COMPARED ACROSS DIFFERENT PERIMETER MODELS
Since different perimeter models vary in design and sensitivity thresholds cannot be directly compared. BOX
sometimes use different test parameters, patients may 12A presents an overview of major causes of variability
perceive perimetric stimuli differently. As a result, the between different Octopus perimeter models as well as
measured sensitivity thresholds can vary¹ and measured the HFA perimeter and Octopus perimeter models.

BOX 12A MAJOR DIFFERENCES BETWEEN VARIOUS OCTOPUS PERIMETER MODELS

Since the various Octopus perimeter models vary in design and sometimes use different test parameters,
measured sensitivity thresholds also vary.¹
Firstly, design differences can lead to a different perception of perimetric stimuli. For example, there are
two fundamentally different designs used in recent Octopus perimeter models. Cupola perimeters (e.g.,
Octopus 101 and 900) allow for testing of the full ield (e.g., 90° radius) and use a moving projector to
present the perimetric stimuli onto the whitish surface of a cupola. On the other hand, screen-based
perimeters (e.g., Octopus 600) allow for testing of the central ield only (e.g., 30° radius) and generate
the stimulus on a computer display. Because of the different stimulus presentation technologies used,
patients may perceive stimuli differently.

In addition, the full ield cupola perimeters are open and thus need to operate under dim room lighting
conditions to avoid stray light inluencing the result, whereas screen-based perimeters are closed,
not inluenced by stray light and thus can be operated under daylight conditions. Further, while the
mechanical projector of the cupola perimeters makes some noise upon stimulus presentation, screen-
based perimeters are silent during stimulus presentations. As a result, even if completely identical
test conditions are used (i.e., same stimulus size, same stimulus luminance and same background
luminance), patients may respond differently. They can be inluenced by these differences and, as a
result, determined sensitivity thresholds may vary.
Secondly, different test parameters may also lead to different perimetric results. For this reason, all
recent Octopus models (e.g., Octopus 900, Octopus 600, Octopus 300 and Octopus 123) use the same
ixed test parameters, which are described in Box 4A. An exception is the Octopus 101, which uses
a background luminance of 4 asb (instead of 31.4 asb), operating under mesopic illumination (i.e.,
midway between daylight and night vision) instead of photopic illumination (i.e., daylight vision), which
may inluence the perception of the perimetric stimulus. To reduce this bias when transitioning from
an Octopus 101 to an Octopus 900, the Octopus 900 can be optionally operated using a background
luminance of 4 asb.

MAJOR DIFFERENCES BETWEEN THE HFA PERIMETER AND OCTOPUS

PERIMETER MODELS

As already explained in the section above, design differences between the HFA perimeter (which is a
cupola perimeter) and other Octopus perimeter models may lead to different perception of perimetric
stimuli even if the same test conditions were used.
However, the HFA perimeter and the various Octopus perimeter models also use different ixed test
parameters. The most marked difference between the determined sensitivity thresholds of an HFA
perimeter and recent Octopus perimeter models (e.g., Octopus 900, 600, 300 and 123) stems from the
different maximum stimulus luminances used (4,000 asb in Octopus perimeters compared to 10,000
General aspects of transitioning 237

asb in HFA perimeters). This difference leads to an offset of 4 dB in the default decibel scale used to
display sensitivity thresholds. This is due to the fact that both instruments take the maximum stimulus
luminance as the origin of their dB scale (0 dB), as explained in BOX 2A. A stimulus of 1,000 asb
intensity therefore corresponds to a sensitivity threshold of 10 dB on an HFA II perimeter and to 6 dB
on an Octopus 900 perimeter.

DEVICE-SPECIFIC NORMATIVE DATABASES ALLOW

COMPARISON OF SENSITIVITY LOSSES BETWEEN DEVICES
SENSITIVITY LOSSES CAN BE COMPARED BETWEEN DIFFERENT OCTOPUS PERIMETER MODELS

Whenever an Octopus perimeter model is developed, an Octopus 300) are imported into another model (e.g.,
data are collected from people with healthy eyes and of Octopus 900), the user can be sure that the imported sen-
different ages on that model in order to develop a nor- sitivity thresholds are compared with the Octopus 300
mative database for it (see BOX 2B for more detail on device-speciic normative database to calculate the sen-
normative databases). As a result, each Octopus model sitivity losses.
has its respective normative database. Furthermore, all
Octopus models contain the normative databases of all Using device-speciic normative databases largely elimi-
other models in order to allow for smooth transitions nates device-speciic differences in sensitivity losses. As
between models. When transitioning from one Octopus a result, sensitivity losses and all related representations,
model to another, the existing data of one device can be with the exception of the Values and Grayscale (Values),
imported into the other device and the data compared to are largely comparable across perimeter models as shown
the appropriate normative database. For example, when in FIG 12-1.
the visual ield tests taken on a given Octopus model (e.g.,

SENSITIVITY LOSSES CAN BE COMPARED BETWEEN HFA PERIMETERS AND DIFFERENT OCTOPUS
PERIMETER MODELS

HFA perimeters use an HFA-speciic normative database measured sensitivity thresholds of an HFA II and an
to calculate the sensitivity losses presented in the Total Octopus 900 show an offset of 4 dB as explained in BOX
Deviation representation, while each Octopus model 12A, the respective normative databases show the same
uses its own normative database. As a result, the use of offset, and as a result the sensitivity losses are comparable.
these device-speciic normative databases largely elimi- This means that all representations with the exception of
nates any model-related bias between perimetric results the Values and Grayscale (Values) representations are
when looking at sensitivity losses. For example, while the comparable.2,3
238 Chapter 12 | Transitioning to a different perimeter model

SENSITIVITY LOSSES BETWEEN DIFFERENT DEVICES ARE LARGELY COMPARABLE

MEASURED SENSITIVITY NORMATIVE VALUES SENSITIVITY LOSSES

THRESHOLDS

Values Normative Database Corrected Probabilities

6 16 20 18
OCTOPUS 900

13 16 23 20 17 19

18 19 23 23 23 21 19 19

17 19 18 24 29 24 19 19 18 19

17 18 20 24 26 28 22 16 17

13 16 24 21 28 27 23 9 11

18 19 20 23 22 21 11 1 5 13

18 20 18 8 5 2 0

15 3 2

5 3

NOT COMPARABLE COMPARABLE

Values Normative Database Corrected Probabilities

5 14 18 17
OCTOPUS 600

10 16 20 21 14 21

17 19 22 22 23 22 21 20

16 21 25 20 25 21 24 21 23 17

18 20 23 24 25 26 23 16 18

18 23 26 23 27 29 22 1 6

21 23 26 26 22 21 11 1 0

23 23 18 8 5 2

15 4 2

5 3

NOT COMPARABLE COMPARABLE

Threshold Values Normative Database Pattern Deviation Probability Map

HFA II

FIGURE 12-1 This example illustrates the benefits of using device-specific normative databases (i.e., an individual normative
database for each device). In this example, sensitivity thresholds of a patient with retinal detachment were determined on
an Octopus 900, Octopus 6 00 and on an HFA II perimeter on the same day (left). These sensitivity thresholds cannot
be compared to each other due to the different characteristics of the three perimeter models. However, because distinct
normative databases are used for the Octopus 900, Octopus 6 00 and the HFA II perimeter (middle), the sensitivity losses are
comparable. Sensitivity losses are calculated as the deviation of the measured sensitivity thresholds of each model from its
respective normative database and are the basis of most visual field representations such as the Corrected Probabilities
or Pattern Deviation Probability Map shown in this figure. Note that comparability applies to all representations with the
exception of the Values and Grayscale (Values) representations.
General aspects of transitioning 239

IMPORT OF EXISTING DATA TO ENSURE CONTINUITY

IMPORT OF EXISTING DATA FROM ONE OCTOPUS PERIMETER MODEL TO ANOTHER

As presented in Chapter 9, a series of visual ield tests data. All current Octopus perimeters therefore allow for
over time is necessary to adequately assess visual ield the import of electronically stored visual ield results
progression in diseases such as glaucoma. When tran- from the Octopus models 500, 101, 123, 300, 900 and
sitioning from one perimeter to another, it is therefore 600. Data can be transferred either in a single session or
essential to be able to use a patient’s existing visual ield on a continuous basis if the other perimeter is still in use.

RAW DATA AFTER IMPORT CAN BE DISPLAYED IN ANY OCTOPUS FORMAT

RAW DATA FROM DIFFERENT DISPLAY IN ANY OCTOPUS FORMAT

PERIMETER MODELS

Values Normative
Database
OCTOPUS 900

6 16 20 18

13 16 23 20 17 19

Octopus HFA-style Octopus 7-in-1

18 19 23 23 23 21 19 19

17 19 18 24 29 24 19 19 18 19

17 18 20 24 26 28 22 16 17

13 16 24 21 28 27 23 9 11
Single field analysis Right eye (OD)
18 19 20 23 22 21 11 1 5 13
Name: Demo John ID: GS_103 Date of birth: 1977/01/01
Demo John, 1977/01/01 (39yrs)
18 20 18 8 5 2 0 32 Right eye (OD) / 08/08/2016 / 09:05:48
15 3 2 Fixation monitor: Min Stimulus: III / 4000 asb / White Pupil diameter: Date: 08/08/2016 Seven-in-One
Fixation target: Cross marks Background: 31 asb / White Visual acuity: null Time: 09:05:48
5 3 Fixation losses: 0/0 Strategy: TOP RX: Age: 39 Grayscale (CO) Values [dB]
False pos errors: 0 % MD [dB] 6 16 20 18
MS [dB]
False neg errors: 0 % 7.5 6.9
[%]
19.4 19.8

Test duration: 02:04 13 16 23 20 17 19

95..100
Fovea: Off 18 19 23 23 23 21 19 19
6 16 20 18 83..94
71..82 17 19 18 24 29 24 19 19 18 19
13 16 23 20 17 19

NOT COMPARABLE
59..70
17 18 20 24 26 28 22 16 17
47..58
18 19 23 23 23 21 19 19
35..46 13 16 24 21 28 27 23 9 11
17 19 18 24 29 24 19 19 18 19 23..34
18 19 20 23 22 21 11 1 5 13
11..22
17 18 20 24 26 28 22 16 17 18 20 18 8 5 2 0
30 30 0..10
13 16 24 21 28 27 23 9 11

Values Normative
15 3 2
11.8 20.6 15.6 7.1

18 19 20 23 22 21 11 1 5 13 5 3

Database Comparison [dB] Corrected comparisons [dB] Defect curve

OCTOPUS 600

18 20 18 8 5 2 <0 0 <0
18 8 + 5 11 + + + Rank
1 74
15 3 2 <0 <0 <0 <0 <0 <0
12 10 + 6 9 6 5 + + + + + -5
5 14 18 17
5 3 <0 <0 <0 <0 8 8 5 5 5 6 8 7 + + + + + + + + 0
5%
10 16 20 21 14 21 9 8 10 + + 5 10 9 9 7 + + + + + + + + + +
Defect (dB)

17 19 22 22 23 22 21 20 9 9 9 5 5 + 7 11 9 + + + + + + + + + 95%
-18 -8 -4 -5 -11 -1 3 2 10
13 11 5 9 + + 6 18 16 6 + + + + + + 11 9
16 21 25 20 25 21 24 21 23 17 -12 -10 -3 -6 -9 -6 -5 -3 4 1 -2 1 15
8 8 8 5 7 8 18 27 22 14 + + + + + + 11 20 15 7
-8 -8 -5 -5 -5 -6 -8 -7 -1 -1 3 2 2 1 -1 0 20
18 20 23 24 25 26 23 16 18 8 7 10 21 23 26 27 + + + 14 16 19 20
-9 -8 -10 -4 0 -5 -10 -9 -9 -7 -2 -1 -3 3 7 2 -3 -2 -2 0 25
18 23 26 23 27 29 22 1 6 11 24 25 + 17 18
-9 -9 -9 -5 -5 -3 -7 -11 -9 -2 -2 -2 2 2 4 0 -4 -2 Diffuse defect [dB]: 7.0
21 23 14 16
21 23 26 26 22 21 11 1 0 -13 -11 -5 -9 -3 -4 -6 -18 -16 -6 -4 2 -2 4 3 1 -11 -9
-8 -8 -8 -5 -7 -8 -18 -27 -22 -14 -1 -1 -1 2 0 -1 -11 -20 -15 -7 MD -10.6 Probabilities Corrected probabilities
23 23 18 8 5 2
-8 -7 -10 -21 -23 -26 -27 -1 0 -3 -14 -16 -19 -20 PSD 7.8
15 4 2 -11 -24 -25 -4 -17 -18

5 3 -21 -23 -14 -16

Total deviation Pattern deviation [%]

P>5
P<5
P<2
P<1

NOT COMPARABLE P < 0,5

30°
Programs: 32 Standard White/White / TOP Questions / repetitions: 74 / 0
MS [dB]: 15.5
Parameters: 31.4 / 4000 asb III 100 ms Duration: 02:04
MD [< 2.0 dB]: 11.6
Catch trials: 0/4 (0%) +, 0/4 (0%) - RF: 0.0

Threshold Normative
Refraction S/C/A: VA [m]: sLV [< 2.5 dB]: 7.8
[%] Pupil [mm]: IOP [mmHg]:
<5 NV: T12 V2.1

Values Database <2

<1
Comment:

< 0.5
OCTOPUS 900 SN3704 OCTOPUS® EyeSuite™ Static perimetry, V3.5.0
OCTOPUS 900, SN 3704, V 2.3.1 / 3.6.0
HFA II

FIGURE 12-2 All recent Octopus perimeter models can import data from other Octopus models and from the HFA II perim-
eter. Because the raw data is imported (i.e., the sensitivity thresholds, reliability indices and general test parameters) and the
Octopus models that allow data import contain device-specific normative databases for all other models, the existing data is
treated as a new measurement. Conseq uently, all representations and printouts available on an Octopus perimeter are avail-
able, including the Octopus HFA-style (middle), the Octopus 7-in-1 printout (right), the Cluster Analysis and the Polar Analysis
(not shown in this example of a retinal detachment case) and any trend analysis (not shown).
240 Chapter 12 | Transitioning to a different perimeter model

To ensure a seamless transition, Octopus perimeters can treat the existing data like any new measurement
import the measured sensitivity thresholds, reliability and display it in exactly the same format as shown in
indices and general test parameters, including infor- FIG 12-2. Potential differences in deinitions of represen-
mation as to which perimeter model the data is coming tations and indices used are thus eliminated and pro-
from. The imported measured sensitivity thresholds gression of visual ield data can be assessed as shown in
are then compared to the relevant normative database FIG 12-3. In addition, this approach offers the advantage
as described in the previous section (e.g., if importing that data taken years ago can be viewed with the latest
existing data from an Octopus 300 into an Octopus 900, analysis tools (e.g., Cluster Trend Analysis).
the measured sensitivity thresholds are compared to
the Octopus 300 normative database). Because all Octo- For full transparency, the device from which a mea-
pus representations are calculated from the measured surement stems is clearly marked on each visual ield
sensitivity thresholds (see FIG 7-1), by comparing them test and assigned a distinct symbol in the global trend
to device-speciic normative databases, the new device analysis.

IMPORT OF EXISTING DATA FROM AN HFA TO AN OCTOPUS PERIMETER

To ensure that existing data collected on an HFA can thresholds and the HFA normative database, thus largely
be used after a transition to an Octopus perimeter, all eliminating device-speciic differences. Because raw data
recent Octopus perimeter models allow import of elec- (i.e., sensitivity thresholds) are imported, the Octopus
tronically stored data from an HFA II. This includes the perimeter can treat the existing data like any new mea-
sensitivity thresholds, general test parameters, perim- surement and display it in exactly the same format as
eter model from which the data stems (HFA II), as well shown in FIG 12-2.
as reliability indices. To largely eliminate the inluence of
any device-related differences at the level of sensitivity To assess visual ield progression, it is important to be
losses, each Octopus perimeter also contains a normative able to use the existing HFA data imported into an Octo-
database for the HFA II perimeter. The sensitivity losses pus perimeter and the new measurements in the same
(i.e., Total Deviation on the HFA-style printout and the trend analysis. This is possible as long as comparable test
Comparisons on the Octopus-style printout) of the HFA parameters (i.e., same stimulus type, same test pattern)
data are then calculated from the imported sensitivity are used. FIG 12-4 provides an example.
General aspects of transitioning 241

OCTOPUS PERIMETERS CAN JOINTLY DISPLAY DATA FROM ANY OCTOPUS PERIMETER IN A TREND ANALYSIS

MD TREND ANALYSIS

MD Mean defect

O’ 123
0
O’ 300

15
Octopus 123
Octopus 300

25
2006 2007 2008 2009 2010 2011 2012 2013 2014

SERIES OF VISUAL FIELDS

OCTOPUS 123 OCTOPUS 300

FIGURE 12-3 All Octopus perimeters allow import of existing patient data to ensure data continuity. The measured sensitivity
thresholds are imported and compared to the appropriate device-specific normative database. The data can then be displayed
in any Octopus format. In the example above, a glaucoma patient with an inferior arcuate defect has been tested on an
Octopus 123 perimeter (unfilled triangle) from 2006 to 2009 using Standard Automated Perimetry (SAP) with a G test pattern.
In 2010, the clinic transitioned to an Octopus 300 (filled triangle) and continued testing the patient with the same test
parameters. The data of both devices can be used in the same Global Trend Analysis to monitor progression. Note that this
patient shows typical levels of fluctuation both before and after the transition.
242 Chapter 12 | Transitioning to a different perimeter model

OCTOPUS PERIMETERS CAN JOINTLY DISPLAY HFA AND OCTOPUS DATA IN A TREND ANALYSIS

MD Mean defect

O’ 900
0
HFA II

15 HFA II Octopus 900

25
2006 2007 2008 2009 2010 2011 2012 2013 2014

SERIES OF VISUAL FIELDS

HFA II OCTOPUS 900

FIGURE 12-4 In this example, a glaucoma patient with a superior arcuate defect has been tested on an HFA II perimeter from
2006 to 2009 using SAP with a 24-2 test pattern. In 2010, the clinic transitioned to an Octopus 900 and continued testing
the patient with the same test parameters. The HFA II data can be imported into the Octopus 900 perimeter and the data of
both devices can be used in the same Global Trend Analysis because of the device-specific normative databases used by the
Octopus perimeters.
S pec ific aspec ts related to transitioning f rom the H um phrey F ield A naly z er 24 3

MANAGING PATIENT-RELATED FLUCTUATION

As described in the sections above, Octopus perimeters learning effects, it is thus good practice for technicians to
offer several features that minimize the impact of the take some examinations with the new device themselves
transition between different perimeter models. Never- and to make sure to include noticeable differences in the
theless, one may still observe differences in some but not patient instructions. Furthermore, running a practice
all patients after switching devices. test with a patient on a new device is also helpful.

This can be explained in part by the fact that patient-related In addition to learning effects, some patients may show
luctuation is always present in perimetry and should personal preferences for one perimeter model over the
therefore also be expected during the transition from one other. For example, while cupola perimeters such as
perimeter to another. During the transition, patient- the Octopus 900 or the HFA II need to be operated under
related luctuation can be associated with the transition dim room light conditions, closed 30° perimeters like the
itself or it may be independent of it. Chapter 3 provides Octopus 600 or 300 may also be operated at daylight
many practical tips on how to minimize patient-related levels. Different ambient light conditions may inluence
luctuation. The transition between perimeter models the patient’s performance during the perimetric test,
itself may increase the amount of patient-related luc- with dim light conditions enhancing concentration in
tuation in some but not all patients. Because the design some, while making others sleepy and less alert. While
and working conditions of different perimeter models personal preferences cannot be eliminated, typically the
vary, some patients may show learning effects during the impact on the visual ield test results is within expected
initial tests on the new device (for more information on levels of luctuation.
learning effects, see FIG 3-12). To minimize the impact of

SPECIFIC ASPECTS RELATED

TO TRANSITIONING FROM THE
HUMPHREY FIELD ANALYZER
SELECTION OF TEST PARAMETERS
As shown in FIG 12-1 and 12-4, visual ield tests taken on TABLE 12-1 provides an overview of the most common
either the HFA or the Octopus perimeter result in com- choices of Octopus test patterns and strategies following
parable test results that can be used equally well for clin- a transition from an HFA perimeter. More detailed infor-
ical decision-making.2-6 However, because both perime- mation on all available Octopus test patterns is presented
ter brands use their own test patterns and strategies to in Chapter 5 and more details on the available test strate-
perform visual ield testing, one may not intuitively know gies are presented in Chapter 6.
which ones to choose on an Octopus perimeter after a
transition from an HFA perimeter.
244 Chapter 12 | Transitioning to a different perimeter model

COMMON CHOICES OF TEST PATTERNS AND STRATEGIES IN HFA TABLE 12-1

AND OCTOPUS PERIMETERS

TEST PATTERN TEST STRATEGY

HFA OCTOPUS HFA OCTOPUS

30° 24-2, 30-2 24-2, 30-2, G SITA Fast TOP

(Glaucoma/ General)
24-2, 30-2 24-2, 30-2, G SITA Standard Dynamic

10° 10-2 10-2, M SITA Fast TOP

(Macula, constricted field,
hydroxy-chloroq uine retinopathy) 10-2 10-2, M SITA Standard Dynamic

FULL FIELD (Threshold) 60-4 07 SITA Standard Dynamic

FULL FIELD (Screening) 81FF, 120FF, 07 3-zone 2LT

135 FF

DRIVING ABILITY Esterman test Esterman test

While EyeSuite Progression Analysis (see Chapter 9) can in the patient’s existing visual ield tests. For this reason,
be performed on tests that use different test strategies, it Octopus perimeters provide the most commonly used
requires the same test pattern and the same overall test HFA test patterns, namely the 24-2, 30-2 (FIG 5-4) and
conditions to be used for all tests included in the visu- 10-2 (FIG 5-10). If any other HFA pattern not available on
al ield series. If progression analyses are needed when an Octopus perimeter is needed, it is possible to create
transitioning from an HFA perimeter to an Octopus perim- that test pattern using the Custom Test function available
eter, it is thus best to select the same test pattern used on some Octopus models.

INTERPRETATION OF A SINGLE VISUAL FIELD

Both Octopus and HFA perimeters have developed their imported on an Octopus perimeter can be displayed using
own brand-speciic visual ield representations. While both the Octopus-style as well as the HFA-style printout.
the underlying reasoning and deinitions are comparable,
they have different names, a different graphical style and HFA and corresponding Octopus representations are
the formulas used in their calculation can vary.7,8 very similar. Once the Octopus-speciic terminology of
each representation becomes familiar, those familiar with
To facilitate the transition from an HFA to an Octopus the HFA terminology can easily interpret the results. FIG
perimeter with minimal training in visual ield interpre- 12-5 presents a side-by-side comparison of all available
tation, all Octopus perimeters offer an HFA mode. In this HFA and Octopus representations and also highlights
mode, an HFA-style printout is available in which the differences relevant for clinical interpretation. Guidance
single ield representations and indices are named and on how to transition from the Glaucoma Hemiield Test
calculated based on the deinitions used in the original HFA (GHT) to the Defect Curve is provided in BOX 12B.
printout. FIG 12-2 shows that any visual ield test taken or
S pec ific aspec ts related to transitioning f rom the H um phrey F ield A naly z er 24 5

SIMILARITIES AND DIFFERENCES BETWEEN HFA AND CORRESPONDING OCTOPUS REPRESENTATIONS

HFA REPRESENTATION CORRESPONDING COMMENTS

OCTOPUS REPRESENTATION

THRESHOLD VALUES VALUES Both perimeters display the

measured sensitivity thresholds.
17 20 20 18
Octopus perimeters display absolute
15 21 22 24 23 27 defects (i.e., sensitivity thresholds 0
5 22 20 22 26 25 27 28 dB) with a “ ” sign (see FIG 7-2 and
7-3).
8 9 16 14 29 27 27 30 29 27

15 13 15 12 30 31 31 28 28 26

26 23 27 28 28 30 31 30 29

19 23 28 28 28 29 29 30 29 26

21 24 28 29 30 30 28 28

23 24 25 29 29 28

25 21 26 28

GRAYSCALE GRAYSCALE (COMPARISONS) Both perimeters use an interpolated

graphical map to assess magnitude
and shape of defects.

The HFA Grayscale is based on

sensitivity thresholds (Threshold
Values) in dB, thus it is influenced
by both patient-age and eccentricity
of test location.

The Octopus Grayscale (Comparisons)

is based on sensitivity loss in % ,
thus its interpretation is independent
of patient-age and eccentricity of test
locations (see FIG 7-7 and 8-18).

TOTAL DEVIATION COMPARISONS Both perimeters display sensitivity

NUMERICAL MAP loss (i.e., deviation from age-corrected
6 + + 6
normal values), but they use opposite
signs.
10 5 5 + + +

21 6 9 7 + + + + Octopus perimeters display sensitivity

18 19 14 17 + + + + + +
loss < 5 dB with a “ + ” sign (see FIG
7-6 and 8-18).
12 16 16 20 + + + + +

+ 6 + + 5 + + + +

7 6 + + + + + + + +

7 5 + + + + + +

5 5 + + + +

+ 6 + +

FIGURE 12-5 Side-by-side comparison of the HFA Single Field Analysis and the Octopus 7-in-1 printout of the same visual
field test that was tak en on an HFA II perimeter and then imported into an Octopus perimeter. Many representations in the
two printouts are based on the same principles, but use different names. It should be noted that while differences between the
results of the two perimeters are present, they are typically very small and do not alter the clinical interpretation of the case.
Small differences in the definitions used between the perimeters are highlighted in the comment column.
246 Chapter 12 | Transitioning to a different perimeter model

PATTERN DEVIATION CORRECTED COMPARISONS Both perimeters display local

NUMERICAL MAP sensitivity loss (i.e., deviation from
+ + + +
age-corrected normal values with a
correction applied to eliminate any
8 + + + + +
influence of diffuse loss).
19 + 7 5 + + + +

16 17 12 15 + + + + + +
Octopus and HFA perimeters use
opposite signs.
10 14 14 18 + + + + +

+ + + + 5 + + + + Octopus perimeters display local

6 + + + + + + + + +
sensitivity loss < 5 dB with a “+” sign
(see FIG 7-16, 7-17 and 8-18).
5 + + + + + + +

+ + + + + +

+ 5 + +

TOTAL DEVIATION PROBABILITIES Octopus and HFA perimeters show

PROBABILITY MAP the same levels of probabilities using
similar symbols.

Octopus perimeters use the

following symbols (see FIG 7-10,
8-14 and 8-15).

p > 5%
p < 5%
p < 2%
p < 1%
p < 0.5 %

PATTERN DEVIATION CORRECTED PROBABILITIES Octopus and HFA perimeters show

PROBABILITY MAP the same levels of probabilities using
similar symbols.

Octopus perimeters use the

following symbols (see FIG 7-19,
8-14 and 8-15).

p > 5%
p < 5%
p < 2%
p < 1%
p < 0.5 %
S pec ific aspec ts related to transitioning f rom the H um phrey F ield A naly z er 2 4 7

MD MD HFA and Octopus perimeters use

opposite signs.
MEAN DEVIATION MEAN DEFECT
HFA perimeters put extra weight on
central visual field locations.
-4.66 dB 4.4 dB
Octopus perimeters weigh each
location equally,7,8 as the standard
G pattern has higher density of
central test locations (see TABLE 7-1
and FIG 8-26).

PSD sLV HFA perimeters put extra weight on

central visual field locations.
PATTERN STANDARD SQUARE ROOT OF LOSS
DEVIATION VARIANCE Octopus perimeters weigh each
location equally, as the standard G
pattern has higher density of central
6.11 dB 5.3 dB test locations (see TABLE 7-1 and
FIG 8-27).

GHT DEFECT CURVE Both GHT and Defect Curve provide

1 Rank 74 information on the overall status of
GLAUCOMA HEMIFIELD TEST -5 the visual field, though the methods
differ.
0
5%

5 For more details, see BOX 12B.

Defect (dB)

Outside normal limits 10 95%

15

20

25

VFI MD Both VFI and MD are measures of

the overall visual field loss, and give
VISUAL FIELD INDEX MEAN DEFECT comparable results in patients with
MD values larger than ±5 dB.

90% 4.4 dB VFI is expressed as a percentage of

normal function, ranges from 100%
to 0 % and is not influenced by
diffuse visual field loss.

MD is expressed in dB, ranges from 0

up to 25 dB and is affected by diffuse
visual field loss but is also more
sensitive in detecting early visual field
loss.9

FALSE POS ERRORS FALSE POSITIVE ANSWERS Both HFA and Octopus perimeters
display the percentage of false
positive errors (see FIG 7-22).
12% 1/8 (12%) +
Octopus perimeters additionally
present the absolute numbers of
false positive answers and the total
number of positive catch trials.
248 Chapter 12 | Transitioning to a different perimeter model

FALSE NEG ERRORS FALSE NEGATIVE ANSWERS Both HFA and Octopus perimeters
display the percentage of false
negative errors (see FIG 7-23).
12% 1/8 (12%) -
Octopus perimeters additionally
present the absolute numbers of
false negative answers and the total
number of negative catch trials.

FIXATION LOSSES NOT AVAILABLE HFA perimeters use the Heijl-Krakau

method to determine the percentage
of fixation losses.
0/12
Octopus perimeters prevent fixation
losses by using Fixation Control, in
which the test is interrupted when
adequate fixation is not maintained
(see FIG 3-11).

GAZE TRACKER NOT AVAILABLE HFA perimeters record eye

movements using the gaze tracker.

Octopus perimeters prevent fixation

losses by using Fixation Control, in
which the test is interrupted when
adequate fixation is not maintained
(see FIG 3-11).

BOX 12B RELATIONSHIP BETWEEN THE GLAUCOMA HEMIFIELD TEST (GHT) AND THE
DEFECT CURVE

The Glaucoma Hemiield Test (GHT) is an intuitive text-based index that provides information about the
overall status of the visual ield and classiies the visual ield results as “Within normal limits”, “Border-
line”, “Outside normal limits”, “General reduction of sensitivity” and “Abnormally high sensitivity”. Its
design is based on the asymmetry of sensitivity thresholds for the superior and inferior arcuate nerve
iber bundle regions. It therefore determines statistically signiicant differences between two corre-
sponding visual ield clusters divided by the horizontal midline.
In Octopus perimeters, the Defect Curve is used to determine overall visual ield status. And while it is
based on different principles, it provides similar information about whether visual ields are normal or
whether local or diffuse defects are present. The table below summarizes some rules of thumb on how
to read the Defect Curve to obtain information that is comparable to the GHT. For more details on the
Defect Curve, refer to FIG 7-11 and 8-10.
S pec ific aspec ts related to transitioning f rom the H um phrey F ield A naly z er 2 4 9

GHT DEFECT CURVE DEFECT CURVE

INTERPRETATION

Rank
1 59
WITHIN NORMAL LIMITS NORMAL
-5

0
5% Defect Curve within normal
5 band
Defect (dB)

10 95%

15

20

25

Rank
1 52 BORDERLINE
BORDERLINE
-5

0
5%
Defect Curve along/slightly
5
below normal band
Defect (dB)

10 95% OR
15 Defect Curve within normal
20 band, but with characteristic
drop on the right (not shown)
25

Rank
1 59
OUTSIDE NORMAL LIMITS LOCAL DEFECT
-5

0
5% Drop of Defect Curve on
5 the right
Defect (dB)

10 95%

15

20

25

Rank
1 59
GENERAL REDUCTION DIFFUSE DEFECT
-5
OF SENSITIVITY
0
5% Parallel downward shift of
5 Defect Curve
Defect (dB)

10 95%

15

20

25

1 Rank 59
ABNORMALLY HIGH TRIGGER-HAPPY
-5
SENSITIVITY
0
5% Steep rise of Defect Curve
5 on the left
Defect (dB)

10 95%

15

20

25
250 Chapter 12 | Transitioning to a different perimeter model

INTERPRETATION OF VISUAL FIELD PROGRESSION

Both HFA and Octopus perimeters offer methods for change and the rate of change. In addition, both HFA
assessing visual field progression. FIG 12-6 presents a and Octopus perimeters provide tools to determine
side-by-side comparison of all available HFA and Octopus whether there is local progression beyond what is ap-
progression analyses and also highlights differences parent in the MD trend analysis and where the change
relevant for clinical interpretation. For more detailed happens. The Octopus also offers a method for identify-
information on EyeSuite Progression Analysis, refer to ing diffuse progression independently. Furthermore,
Chapter 9. to facilitate the combined evaluation of structural and
functional progression in glaucoma, Octopus perimeters
To judge whether a visual ield series is stable or pro- offer a trend procedure, the Polar Trend Analysis, which
gressing, both HFA and Octopus perimeters use a trend facilitates inding a relationship between structural and
analysis approach and determine both signiicance of functional losses.

OVERVIEW OF PROGRESSION TOOLS AVAILABLE ON HFA AND OCTOPUS PERIMETERS

HFA REPRESENTATION OCTOPUS REPRESENTATION COMMENTS

GUIDED PROGRESSION EYESUITE PROGRESSION GPA uses both trend analysis

ANALYSIS (GPA) ANALYSIS and point-wise event analysis,
which req uires two reliable
baseline tests.

EyeSuite Progression
Analysis uses trend analysis.

GPA TREND ANALYSIS MD TREND ANALYSIS Both perimeters use trend

analysis to determine signi-
ficance and rate of change.
OVERALL PROGRESSION

VFI MD Mean defect

100%
HFA uses the Visual Field
0
80% Index (VFI), which typically
60% ranges from 100% to 0% .
Significant change is shown
40%
in text.
20%
15 Octopus uses the Mean
0%
74 AGE 84 94 Defect (MD), which typically
ranges from 0 to 25 dB.
Rate of progression: -2.6 ± 1.8% Significant worsening is
(95% confidence) 25
2015
shown with red downward
Slope significant at P < 5% Slope: 0.5 dB / Yr (p<0.5%) arrows (see FIG 9-6).

FIGURE 12-6 Side-by-side comparison of the HFA and the Octopus progression analyses of the same visual field series
that was tak en on an HFA II perimeter and then imported into an Octopus perimeter. Some analyses identify similar aspects
of progression, such as whether there is progression and where localiz ed progression occurs, but use a different approach.
Further, the Octopus perimeter offers analyses for identifying diffuse progression and providing guidance on where to look for
structural progression. Differences in the methods used between the perimeters are presented in the comment column.
S pec ific aspec ts related to transitioning f rom the H um phrey F ield A naly z er 2 5 1

GPA EVENT ANALYSIS (CORRECTED) CLUSTER HFA uses point-wise event

TREND ANALYSIS analysis to assess local
Deviation from Baseline progression and requires two
trustworthy baseline tests.
GPA Alert displays likelihood
0.8 of progression as text.
0.8

Octopus uses trend analysis

0.2 1.0
0.1 to determine significance
0.1
and rate of change of the
0.2 0.2 variables (see FIG 9-8)
LOCAL PROGRESSION

0.2 • (Corrected) Cluster MD

0.7
(average defects of 10
clusters following RNFL
distribution on the retina,
see FIG 9-11)
Progression Analysis LD TREND ANALYSIS • LD (Local Defect, see
BOX 7D)
LD Local defect
0
LOCAL PROGRESSION

• sLV (Octopus equivalent

of PSD, see FIG 8-27)

Trend analysis is relatively

robust to outliers.
Furthermore, individual
visual fields can be easily
excluded from the trend
analysis in the Octopus
perimeter by simply clicking
15 on a given test.
2015
Slope: 0.5 dB / Yr (p<0.5%)

POSSIBLE PROGRESSION sLV TREND ANALYSIS

sLV Loss variance
LOCAL PROGRESSION

5
2015
Slope: 0.4 dB / Yr (p<5%)
252 Chapter 12 | Transitioning to a different perimeter model

NOT AVAILABLE DD TREND ANALYSIS Octopus uses trend analysis

to determine significance
DD Diffuse defect and rate of change of the
DIFFUSE PROGRESSION

variable DD (Diffuse Defect,

0 see BOX 7C).

25
2015
Slope: 0.1 dB / Yr

NOT AVAILABLE POLAR TREND ANALYSIS Octopus uses Polar Trend

STRUCTURAL PROGRESSION

Analysis to show point-wise

progression per visual field
WHERE TO LOOK FOR

location projected onto the

optic disc as guidance on
where to look for structural
progression (see FIG 9-14).
S
30 20 10 N T
[dB]
I
References 253

REFERENCES
1. Anderson DR, Feuer WJ, Alward WL, Skuta GL. Threshold equivalence between perimeters. Am J Ophthalmol.
1989;107:493-505.
2. Monsalve B, Ferreras A, Calvo P, et al. Diagnostic ability of Humphrey perimetry, Octopus perimetry, and optical coherence
tomography for glaucomatous optic neuropathy. Eye (Lond). 2017;31:443-451.
3. Rajalakshmi AR, Suma E, Prabhu DR. Comparative analysis of visual ield plotting by Octopus Interzeag 1-2-3, Humphrey
Field Analyser II and Frequency Doubling Perimetry in glaucoma patients in South Indian population. J Clin Diagn Res.
2015;9:NC01-3.
4. King AJ, Taguri A, Wadood AC, Azuara-Blanco A. Comparison of two fast strategies, SITA Fast and TOP, for the assessment
of visual ields in glaucoma patients. Graefes Arch Clin Exp Ophthalmol. 2002;240:481-487.
5. Pierre-Filho Pde T, Schimiti RB, de Vasconcellos JP, Costa VP. Sensitivity and speciicity of frequency-doubling technology,
tendency-oriented perimetry, SITA Standard and SITA Fast perimetry in perimetrically inexperienced individuals. Acta
Ophthalmol Scand. 2006;84:345-350.
6. Wadood AC, Azuara-Blanco A, Aspinall P, Taguri A, King AJ. Sensitivity and speciicity of frequency-doubling technology,
tendency-oriented perimetry, and Humphrey Swedish interactive threshold algorithm-fast perimetry in a glaucoma
practice. Am J Ophthalmol. 2002;133:327-332.
7. Funkhouser A, Fankhauser F. The effects of weighting the "mean defect" visual ield index according to threshold
variability in the central and midperipheral visual ield. Graefes Arch Clin Exp Ophthalmol. 1991;229:228-231.
8. Funkhouser AT, Fankhauser F. A comparison of the mean defect and mean deviation indices within the central 28 degrees
of the glaucomatous visual ield. Jpn J Ophthalmol. 1990;34:414-420.
9. Artes PH, O'Leary N, Hutchison DM, et al. Properties of the statpac visual ield index. Invest Ophthalmol Vis Sci.
2011;52:4030-4038.
 255

CHAPTER 13
CLINICAL CASES

INTRODUCTION
The previous chapters of this book have systematically relevant clinical information. Background information on
presented various aspects of visual field testing and the patient’s history as well as other diagnostic results
interpretation. To conclude, visual ield interpretation such as visual acuity, IOP, fundus images, OCT scans and
is now put into a clinical context. In this chapter, 23 clin- MRIs which are relevant for clinical decision making, are
ical cases are presented that show visual ields or visual shown. In all examples, visual acuity is expressed in dec-
ield series of patients with glaucoma, neuro-ophthal- imal units for uniformity, but the Octopus allows users to
mic disorder and retinal disease. The selected cases are select different units when performing the test. In each
model cases. They present typical defect patterns of the case, key diagnostic indings leading to disease diagnosis
disease rather than unusual cases and are reliable, free are presented and summarized.
of artifacts and can be fully trusted.
An overview of all available cases is presented on the
To link visual ield interpretation to the clinical situation, next page.
the visual ield results are presented in addition to other
256 Chapter 13 | Clinical cases

GLAUCOMA – SINGLE FIELD NEUROLOGICAL DISEASES

1. Very early stage glaucoma 16. Cerebral infarction
(normal tension glaucoma) (bilateral)
2. Early stage glaucoma 17. Leber hereditary optic neuropathy
(normal tension glaucoma) (bilateral)
3. Early stage glaucoma 18. Bilateral optic neuritis
(primary open-angle glaucoma) (multiple sclerosis)
4. Early stage glaucoma 19. Tuberculum sellae meningioma
(with cataract) (bilateral)
5. Early stage glaucoma
(normal tension glaucoma)
6. Early stage glaucoma
RETINAL DISEASES
(primary open-angle glaucoma) 20. Age-related macular degeneration
7. Moderate glaucoma 21. Branch central retinal artery occlusion
(normal tension glaucoma) 22. Macular hole
8. Moderate glaucoma 23. Branch central retinal vein occlusion
(primary open-angle glaucoma)
9. Late stage glaucoma
(normal tension glaucoma)

GLAUCOMA – TREND
10. Early to moderate glaucoma
(normal tension glaucoma)
11. Early to moderate glaucoma
(primary open-angle glaucoma)
12. Early to moderate glaucoma
(primary open-angle glaucoma)
13. Early to moderate glaucoma
(normal tension glaucoma)
14. Early to moderate glaucoma
(primary open-angle glaucoma)
15. End-stage glaucoma
(exfolitative glaucoma)
G lauc om a | S ingle field 2 5 7

1 VERY EARLY STAGE GLAUCOMA (NORMAL TENSION GLAUCOMA)

PATIENT • 57-year-old female, no family history

• Patient reported decreased visual acuity in both eyes and discomfort in left eye
IOP/VA corr • 15 mmHg/ 1.2 - 5.25 (sph)
FUNDUS • C/D = 0.9
• Rim thinning at 6 to 11 o'clock position
• Optic disc hemorrhage and narrow slit-like RNFL defect at 11 o'clock position
• Temporal alpha zone and beta zone peripapillary chorioretinal atrophy (PPA)

Demo Jane, 1947/01/01 (57yrs)

Right eye (OD) / 2004/11/18 / 12:01:27
Seven-in-One

Grayscale (CO) Values

22 25 23 26
-1.6 -1.9 27.4 27.9
95%..100%
28 28 27 27 28 29
83%...94%
71%...82% 28 28 30 28 28 29 28 29

59%...70% 26 29 30 29 30 31 29 29 26 28
47%...58%
21 26 29 30 30 31 32 28 27
35%...46%
23%...34% 26 28 28 26 33 30 31 29 29
11%...22%
26 28 29 29 29 29 30 31 29 31
0%...10%
28 29 27 31 31 27 27 30

27 29 28 29 28 28
-1.1 -1.3 27.9 28.8
26 28 27 28

Comparisons Corrected comparisons Defect curve

+ + + + + + + + Rank
1 74

+ + + + + + + + + + + + -5

+ + + + + + + + + + + + + + + + 0
5%
+ + + + + + + + + + + + + + + + + + + + 5
Defect Curve
Defect (dB)

+ + + + + + + + + 5 + + + + + + + +
10 in normal
95%

+ + + + + + + + + + + + 5 + + + + +
15 range
+ + + + + + + + + + + + + + + + + + + +
20
+ + + + + + + + + + + + + + + +
25
+ + + + + + + + + + + +
Diffuse defect [dB]: -1.1
+ + + + + + + +

Probabilities Corrected probabilities

All test
locations
at p > 5%
p>5
p<5
p<2
p<1
p < 0,5

Programs: 32 Standard White/White / Normal Questions / repetitions: 520 / 0 30°

Parameters: 4 / 1000 asb III 100 ms Duration: 16:41 MS [dB]: 28.0
Catch trials: 0/26 (0%) +, 1/26 (4%) - RF: 1.9 MD [< 2.0 dB]: -1.5
Refraction S/C/A: -3.25// VA: 1.0 sLV [< 2.5 dB]: 1.8
Pupil [mm]: IOP [mmHg]: CsLV [dB]: 1.5
SF [dB]: 1.6
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• No visual ield loss

• Fundus indings show changes indicative of very early glaucoma including neuroretinal rim loss, optic disc
hemorrhage, and RNFL loss
258 Chapter 13 | Clinical cases

2 EARLY STAGE GLAUCOMA (NORMAL TENSION GLAUCOMA)

PATIENT • 53-year-old female, no family history

• Optic nerve cupping observed during unrelated emergency eye surgery
IOP/VA corr • 12 mmHg/ 1.2 + 0.25 (sph)
FUNDUS • C/D = 0.8
• Rim thinning and RNFL loss at 5 to 6 o'clock position

Demo Jane, 1942/01/01 (53yrs)

Left eye (OS) / 1996/06/21 / 14:24:40
Seven-in-One

Grayscale (CO) Values

26.2 23 21 20.0
0.7 6.9
95%..100%
23 24 21 24 24 14
83%...94%
71%...82% 26 27
28 27 18 21
59%...70%
28 25 27 23 24
47%...58% 28 26 16 24 17 10
35%...46% 32 32 23 17
34
30 34 33 32
23%...34% 29 30 33 31 28 25
11%...22% 27 30 30
31 32
0%...10% 28 25 31 27
30 27

27 27 28 28 27 23
-0.3 -0.9 28.5 28.6
27 27

Comparisons Corrected comparisons Defect curve

Rank
+ + + + 1 74

+ + + + + 11 + + + + + 10 -5

+ + + + 0
+ + 9 + + + 9 + 5%

+ + + 6 5 + + + 6 5 5
Defect (dB)

+ + 14 5 10 15 + + 14 5 10 15
+ + 9 13 + + 9 13 10 95%
+ +
+ + + + + + + +
+ + + + + + + + + + + + 15
+ + + + + + + + + +
+ + + + + + + + 20
+ + + +
25
+ + + + + + + + + + + +
Diffuse defect [dB]: -1.1
+ + + +

Probabilities Corrected probabilities

Cluster of
abnormal locations
with p < 0.5 %
p>5
p<5
p<2
p<1
p < 0,5

Programs: G Standard White/White / Normal Questions / repetitions: 481 / 1 30°

Parameters: 4 / 1000 asb III 100 ms Duration: 16:49 MS [dB]: 25.9
Catch trials: 0/24 (0%) +, 1/24 (4%) - RF: 2.0 MD [< 2.0 dB]: 1.6
Refraction S/C/A: // VA: 1.2 sLV [< 2.5 dB]: 4.2
Pupil [mm]: 5.3 IOP [mmHg]: 12 CsLV [dB]: 3.9
SF [dB]: 1.7
Comment: NTG
Classification:

OCTOPUS® OCTOPUS 101

• Mild superior nasal step and mild superior paracentral scotoma

• Spatial relationship between visual ield loss and both rim thinning and RNFL loss in fundus photo
G lauc om a | S ingle field 2 5 9

3 EARLY STAGE GLAUCOMA (PRIMARY OPEN-ANGLE GLAUCOMA)

PATIENT • 56-year-old female, her brother has POAG

• Patient visited clinic to rule out glaucoma because of her family history
IOP/VA corr • 24 mmHg /1.0 - 3.25 (sph)
FUNDUS • Inferior RNFL defects
OCT • RNFL and ganglion cell loss inferotemporally at 7 to 8 o’clock position

Demo Jane, 1958/01/01 (56yrs)

Right eye (OD) / 2015/01/09 / 01:31:08
Four-in-One

Grayscale (CO) Cluster analysis [dB]

MD [dB]
2.2 2.5

Nasal step,
3.1 superior arcuate
and superior
+
paracentral defect
5.4 +
7.4

+
+ +

+
+

-1.0 -0.5

Defect curve Polar analysis

Rank
1 59

-5

0
5%

5
Defect (dB)

S
10 95% T N 10 20 30 RNFL loss
[dB]
I inferortemporally
15

20 Local defect
(glaucoma)
25

Diffuse defect [dB]: 2.3 Structural damage

suggested at 7 to 8
o'clock position
30°
Programs: G Standard White/White / TOP Questions / repetitions: 72 / 0
MS [dB]: 26.4
Parameters: 31.4 / 4000 asb III 100 ms Duration: 02:18
Catch trials: 0/4 (0%) +, 0/4 (0%) - RF: 0.0
MD [< 2.0 dB]: 0.9
Refraction S/C/A: VA [m]: sLV [< 2.5 dB]: 4.5
Pupil [mm]: 3.0 IOP [mmHg]:
NV: T31 V1.0

Comment:

GC thinning
inferortemporally
OCTOPUS ® EyeSuite™ Static perimetry, V3.5.0
OCTOPUS 300

• Nasal step, superior arcuate and superior paracentral defect apparent in Cluster Analysis
• Spatial relationship between visual ield loss (Polar Analysis suggests structural damage at 7 to 8 o'clock
position) and inferotemporal structural loss (fundus photo, RNFL & GC thickness map)
260 Chapter 13 | Clinical cases

4 EARLY STAGE GLAUCOMA (WITH CATARACT)

PATIENT • 71-year-old male, no family history

• Patient reported defective vision in both eyes over the last 6 months and glare at night
while crossing roads
IOP/VA corr • 24 mmHg/ 0.7 + 1.75 (sph), - 1.25 (cyl) x 80°
FUNDUS • Fundus image hazy due to cataract
OCT • RNFL loss and ganglion cell loss at 5 to 6 o’clock position

Demo John, 1944/01/01 (71yrs)

Left eye (OS) / 2015/04/29 / 14:57:18
Four-in-One

Grayscale (CO) Corrected cluster analysis [dB]

Hazy due to
MD [dB]
4.2 6.4 cataract
2.2 Nasal step
+
(local defect)

+ 7.4
+

+
+ +

+
+

0.1 2.5

Defect curve Polar analysis

Rank
Diffuse defect
1 59

-5
(cataract)

0
5%

5
Defect (dB)

S
10 95% 30 20 10 Structural
N T
[dB]
I
damage
15
suggested at
5 to 6 o'clock
Local defect position
20
(glaucoma)
25

Diffuse defect [dB]: 2.3

30°
Programs: G Standard White/White / TOP Questions / repetitions: 74 / 0
MS [dB]: 23.0
Parameters: 31.4 / 4000 asb III 100 ms Duration: 02:25
Catch trials: 2/4 (50%) +, 0/4 (0%) - RF: 25.0
MD [< 2.0 dB]: 3.3
Refraction S/C/A: VA [m]: sLV [< 2.5 dB]: 3.4
Pupil [mm]: 3.7 IOP [mmHg]:
NV: T31 V1.0

Comment:

OCTOPUS® EyeSuite™ Static perimetry, V3.5.0

OCTOPUS 300

• Both diffuse defect (due to cataract) and local defect (due to glaucoma) in Defect Curve
• Corrected Cluster Analysis (removing diffuse defect) shows superior nasal step
• Spatial relationship between visual ield loss (Polar Analysis suggests structural damage at 5 to 6 o'clock
position) and inferotemporal structural loss (fundus photo, RNFL & GC thickness map)
G lauc om a | S ingle field 2 6 1

5 EARLY STAGE GLAUCOMA (NORMAL TENSION GLAUCOMA)

PATIENT • 58-year-old female, father had glaucoma

• Optic nerve cupping detected during routine medical visit
IOP/VA corr • 16 mmHg/ 1.2 - 1.0 (sph), - 0.75 (cyl) x 80°
FUNDUS • C/D = 0.9
• Rim thinning and wide RNFL loss at 5 to 6 o'clock position

Demo Jane, 1944/01/01 (58yrs)

Left eye (OS) / 2003/03/14 / 16:43:49
Seven-in-One

Grayscale (CO) Values

19.8 20 21 23.2
6.9 3.4
95%..100% Absolute defect
21 21 22 23 24 23
83%...94% (sensitivity threshold 0 dB)
71%...82% 27 27
25 23 24 23
59%...70%
27 23 28
47%...58% 24 21 15 21 26 18
35%...46% 21 27 24 31
32
31 31 33 31
23%...34% 29 36 32 30 29 26
11%...22% 28 29 29
32 30
0%...10% 27 27 28 26
29 30

26 26 28 27 24 23
-0.7 -0.5 28.6 28.0
26 26

Comparisons Corrected comparisons Defect curve

+ + + + 1 Rank 74

+ + + + + + + + + + + + -5

+ + + + 0
+ + + + + + + + 5%
+ 5 + + 5 + 5
Defect (dB)

+ 8 15 7 + 7 + 8 14 7 + 6
8 + 7 + 8 + 7 + 10 95%
+ +
+ + + + + + + +
+ + + + + + + + + + + +
15
+ + + + + +
+ + + +
+ + + + + + + + 20
+ + + +
25
+ + + + + + + + + + + +
Diffuse defect [dB]: -1.1
+ + + +

Probabilities Corrected probabilities

p>5
p<5
p<2
p<1
p < 0,5

Programs: G Standard White/White / Normal Questions / repetitions: 459 / 0 30°

Parameters: 4 / 1000 asb III 100 ms Duration: 15:23 MS [dB]: 25.0
Catch trials: 3/23 (13%) +, 0/23 (0%) - RF: 6.5 MD [< 2.0 dB]: 2.2
Refraction S/C/A: +0.5/-0.75/80 VA: 1.2 sLV [< 2.5 dB]: 5.8
Pupil [mm]: 5.0 IOP [mmHg]: 13 CsLV [dB]: 5.5
SF [dB]: 2.8
Comment: Gla
Classification:

OCTOPUS® OCTOPUS 101

• Dense paracentral scotoma

• Spatial relationship between visual ield loss and both rim thinning and RNFL loss in fundus photo
262 Chapter 13 | Clinical cases

6 EARLY STAGE GLAUCOMA (PRIMARY OPEN-ANGLE GLAUCOMA)

PATIENT • 55-year-old male, no family history

• Patient reported decreased visual acuity and blurred vision
IOP/VA corr • 23 mmHg/ 1.2 - 4.25 (sph), - 1.0 (cyl) x 180°
FUNDUS • C/D = 0.8
• Small disc
• Rim thinning at 5 to 6 o'clock position

Demo John, 1951/01/01 (55yrs)

Left eye (OS) / 2007/05/11 / 10:02:54
Seven-in-One

Grayscale (CO) Values

25.6 24 23 11.7
1.2 15.1
95%..100%
27 26 25 23 19 15
83%...94%
71%...82% 17 18
29 21 6 6
59%...70%
27 21 23 3 9
47%...58% 28 31 10 3 5 4
35%...46% 30 33 32 3
34
31 33 31 31
23%...34% 30 31 32 30 30 29
11%...22% 29 31 30
31 30
0%...10% 29 30 28 27
31 31

29 31 30 30 24 28
-2.0 -1.4 30.1 29.0
30 29

Comparisons Corrected comparisons Defect curve

Rank
+ + + + 1 74

-5
+ + + + 5 9 + + + + 6 10

10 10 10 10 0
5%
+ 6 21 19 + 7 22 20
+ 7 6 26 20 + 8 7 26 21 5
Defect (dB)

+ + 20 26 22 21 + + 21 26 22 22 95%
+ + + 27 + + + 28 10
+ +
+ + + + + + + +
+ + + + + + + + + + + + 15
+ + + + + + + + + + Local
20
defect
+ + + + + + + +
+ + + +
25
+ + + + + + + + + + + +
Diffuse defect [dB]: -1.1
+ + + +

Probabilities Corrected probabilities

p>5
p<5
p<2
p<1
p < 0,5

Programs: G Standard White/White / Normal Questions / repetitions: 447 / 0 30°

Parameters: 4 / 1000 asb III 100 ms Duration: 13:43 MS [dB]: 24.2
Catch trials: 0/22 (0%) +, 0/23 (0%) - RF: 0.0 MD [< 2.0 dB]: 3.3
Refraction S/C/A: -2.75/-1.0/180 VA: 1.0 sLV [< 2.5 dB]: 8.7
Pupil [mm]: 6.7 IOP [mmHg]: CsLV [dB]: 8.6
Very reliable test SF [dB]: 1.5
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• Visual ield shows superior arcuate defect

• Spatial relationship between visual ield loss and rim thinning in fundus photo indicative of glaucoma
G lauc om a | S ingle field 2 6 3

7 MODERATE GLAUCOMA (NORMAL TENSION GLAUCOMA)

PATIENT • 57-year-old female, no family history

• Patient reported decreased visual acuity in both eyes and discomfort in left eye
IOP/VA corr • 16 mmHg/ 1.0 - 5.5 (sph)
FUNDUS • C/D = 0.95
• Rim thinning at 12 to 6 o'clock position
• Vein angulation and bayoneting at 12 and 6 o'clock position

Demo Jane, 1947/01/01 (57yrs)

Left eye (OS) / 2004/11/18 / 12:25:31
Seven-in-One

Grayscale (CO) Values

24 17 20 23
1.9 14.1 24.1 11.7
95%..100%
29 27 25 23 22 15
83%...94%
71%...82% 27 27 25 25 22 20 13 11

59%...70% 28 28 27 16 2 6 3 2
47%...58%
28 28 24 32 29 1 4 9 4
35%...46%
23%...34% 28 28 27 31 32 26

11%...22%
28 27 29 11 24 17 1
0%...10%
27 28 28 18 3 17 14

26 29 29 22 27 26
1.6 14.5 25.9 12.3
27 27 26 26

Comparisons Corrected comparisons Defect curve

+ 6 + + + 5 + + Rank
1 74

+ + + + + 9 + + + + + 8 -5

+ + + + 5 6 13 13 + + + + 5 6 12 13 0
5%
+ + + 11 26 22 23 22 + + + 11 26 22 22 22
5
Defect (dB)

+ + 5 + + 29 24 18 21 + + + + + 28 24 17 20 95%
10
+ + + + + + + + + + + +
15
+ + + 18 6 12 24 + + + 17 5 11 23
20
+ + + 10 24 10 11 + + + 10 24 9 10
25
+ + + 5 + + + + + + + +
Diffuse defect [dB]: -1.1

+ + + + + + + +

Probabilities Corrected probabilities

p>5
p<5
p<2
p<1
p < 0,5

Large sLV shows

Programs:
Parameters:
32 Standard White/White / Normal
4 / 1000 asb III 100 ms
Questions / repetitions:
Duration:
642 / 0
21:13
severe 30°
local defect
MS [dB]: 18.4
Catch trials: 0/32 (0%) +, 2/33 (6%) - RF: 3.0 MD [< 2.0 dB]: 8.2
Refraction S/C/A: -3.25// VA: 1.0 sLV [< 2.5 dB]: 10.9
Pupil [mm]: 5.8 IOP [mmHg]: CsLV [dB]: 11.0
SF [dB]: 2.2
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• Dense partial double arcuate visual ield defect

• Spatial relationship between visual ield loss and both rim thinning and vein bending in fundus photo
264 Chapter 13 | Clinical cases

8 MODERATE GLAUCOMA (PRIMARY OPEN-ANGLE GLAUCOMA)

PATIENT • 52-year-old female, no family history

• Patient diagnosed with glaucoma during medical check-up
IOP/VA corr • 20 mmHg/ 1.2 - 4.0 (sph), - 0.25 (cyl) x 180°
FUNDUS • C/D = 0.9
• Rim thinning at 6 to 8 o'clock position and notching at 11 o’clock position
• Large RNFL loss at 6 to 8 o'clock position and small RNFL loss at 11 o’clock position
• Angulation of lower vein and undermining due to optic disc cupping
• Temporal alpha zone and beta zone peripapillary chorioretinal atrophy (PPA)

Demo Jane, 1954/01/01 (52yrs)

Right eye (OD) / 2007/02/06 / 09:27:13
Seven-in-One

Grayscale (CO) Values

3.1 5 18.4
23.9 8.7
95%..100%
11 9 21 15
83%...94%
71%...82% 12 21
1 24 23
59%...70%
11 12 15 24
47%...58% 28
35%...46% 6 7 33 30
27
28 29 33 31
23%...34% 7 14 16 29 29 29
11%...22% 21 31 25
24 27
0%...10% 9 18 28 26
25 26

11 22 26 27 26 27
7.9 0.8 20.0 27.5
25 24

Comparisons Corrected comparisons Defect curve

Rank
19 16 1 74

15 16 5 10 12 13 + 7 -5

16 6 13 + 0
5%
27 + + 24 + +
18 17 13 + 15 14 10 + 5
Defect (dB)

+ +
24 24 + + 21 21 + + 10 95%
6 +
+ + + + + + + +
19 14 13 + + + 16 11 11 + + + 15
Absolute 8defects
6 +
+ + 5
+ +
+ +
20
18 11 + + 15 8 + +
(sensitivity threshold
+ +0 dB) + +
25
13 + + + + + 10 + + + + +
Diffuse defect [dB]: -1.1
+ + + +

Probabilities Corrected probabilities

p>5
p<5
p<2
p<1
p < 0,5

Programs: G Standard White/White / Normal Questions / repetitions: 448 / 4 30°

Parameters: 4 / 1000 asb III 100 ms Duration: 14:18 MS [dB]: 17.2
Catch trials: 0/22 (0%) +, 5/23 (22%) - RF: 11.1 MD [< 2.0 dB]: 10.4
Refraction S/C/A: -3.0/-0.25/180 VA: 1.2 sLV [< 2.5 dB]: 10.4
Pupil [mm]: IOP [mmHg]: 13 CsLV [dB]: 10.3
SF [dB]: 2.1
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• Dense visual ield loss in superior nasal quadrant with many locations showing absolute defects and
little remaining sensitivity near ixation corresponding with RNFL loss at 6 to 8 o’clock position
• Mild sensitivity loss on lower nasal ield relating to RNFL loss at 11 o’clock position
G lauc om a | S ingle field 2 6 5

9 LATE STAGE GLAUCOMA (NORMAL TENSION GLAUCOMA)

PATIENT • 52-year-old male, no family history

• Patient reported decreased visual acuity in both eyes
IOP/VA corr • 15 mmHg/ 1.2 + 1.25 (sph), - 0.5 (cyl) x 80°
FUNDUS • C/D = 1.0
• Rim disappearance at 12 and 6 to 8 o’clock position
• Narrowing of retinal artery

Demo John, 1954/01/01 (52yrs)

Right eye (OD) / 2006/11/24 / 16:24:03
Seven-in-One

Grayscale (CO) Values

0.8 2 4 13.0
26.2 14.0
95%..100%
9 6 7 15
83%...94%
71%...82%
5 18
59%...70%
1 21
47%...58% 27 24
35%...46% 3 28 29
30
29 25 28
23%...34% 28 26 20
11%...22% 1 21
0%...10% 15 20

1 5 14 14 17
22.9 13.3 5.0 15.0
12 13

Comparisons Corrected comparisons Defect curve

1 Rank 74
22 20 12 11
-5
17 19 19 10 7 10 9 +

0
5%
23 9 13 +
28 5 18 + 5
Defect (dB)

+ + + + 95%
29 + + 19 + + 10
+ +
+ 7 + + + +
+ 5 8 + + + 15
29 6 19 +
13 7 + + 20

25
25 22 14 14 10 15 13 5 + +
Diffuse defect [dB]: -1.1
14 14 + +

Probabilities Corrected probabilities

p>5
p<5
p<2
p<1 120 105 90 75 60
p < 0,5
135 45

150 30

30° 165 15
Programs: G Standard White/White / Normal Questions / repetitions: 438 / 0
Parameters: 4 / 1000 asb III 100 ms Duration: 13:53 MS [dB]: 8.6
Catch trials: 0/22 (0%) +, 11/22 (50%) - RF: 25.0 MD [< 2.0 dB]: 19.0 180 10 30 40 50 60 70 80 90 0
Refraction S/C/A: +2.75/-0.5/80 VA: 1.0 sLV [< 2.5 dB]: 10.1
Pupil [mm]: IOP [mmHg]: 16 CsLV [dB]: 10.0
SF [dB]: 2.4 195 345
Comment:
Classification:
210 330

OCTOPUS ®
OCTOPUS 101
225

240 255 270 285 300

315

• Dense double arcuate defect with many locations showing absolute defects
• No sensitivity loss at ixation
• Kinetic perimetry shows intact temporal and central visual ield
• Late stage glaucoma with preserved ixation and peripheral temporal visual ield
266 Chapter 13 | Clinical cases

10 EARLY TO MODERATE GLAUCOMA (NORMAL TENSION GLAUCOMA)

PATIENT • 40-year-old male, no family history

• Glaucoma was suspected after routine medical check-up
IOP/VA corr • 16 mmHg/1.2 - 2.5 (sph), - 1.5 (cyl) x 110°
FUNDUS • 1998 Rim thinning RNFL loss at 7 o’clock position
• 2007 Rim thinning & RNFL loss at 6 to 8’clock position indicating progression

Cluster MD change
MD Mean defect sLV Loss variance 1.1 – 2.4 dB/year
0

0 2.4
1.9

1.9 -0.0
1.1 S
30 20 10
N T
0.0 [dB]
I
0.1 -0.2
15

MD change -0.1
-0.0
0.8 dB/year
25 15 Structural progression
2007 2007
Slope: 0.8dB / Yr (p<0.5%) Slope: 0.7dB / Yr (p<0.5%) suggested at 6 to 8
o'clock position

DD Diffuse defect LD Local defect

0

0 1998 2007

25 15
2007 2007
Slope: 0.0dB / Yr Slope: 1.0dB / Yr (p<0.5%)

1998 2007

• Grayscale series shows expansion of superior nasal defect to a superior arcuate defect from 1998
to 2007
• Signiicant (p < 1%) MD worsening at 0.8 dB/year due to fast progression in affected superior clusters
(Cluster MD change 1.1 to 2.4 dB/year)
• Large (up to 30 dB) progression at 6 to 8 o’clock position in Polar Trend Analysis
• Rim thinning and RNFL loss spreading from 7 o’clock position towards 6 and 8 o’clock position
• Clear relationship between fundus and visual ield progression conirming glaucomatous progression
Glaucoma | Trend 267

11 EARLY TO MODERATE GLAUCOMA (PRIMARY OPEN-ANGLE GLAUCOMA)

PATIENT • 68-year-old female, no family history

• High IOP identiied during visit initiated due to eye pain
IOP/VA corr • 22 mmHg/1.5 + 0.75 (sph), - 0.25 (cyl) x 10°
FUNDUS • 2001 Mild, slit-like RNFL loss at 7 o’clock position. No rim thinning or notching.
• 2008 RNFL loss & additional rim thinning with undermining at 6 to 8 o’clock position
indicating progression; laser scar at 1 to 3 o’clock position due to treated BRVO, which
developed in 2002 during follow up

MD Mean defect sLV Loss variance

0

0 1.8
1.1

2.1 0.3
1.9 S
30 20 10
N T
-0.2 [dB]
I
-0.3 0.5
15

-0.4
0.1
MD change
25 0.4 dB/year 15 Structural progression
2001 2008 2001 2008 suggested at 6 to 8
Slope: 0.4dB / Yr (p<0.5%) Slope: 0.8dB / Yr (p<0.5%) o'clock position

DD Diffuse defect LD Local defect

0

0 2001 2008

Large progression at
25 15 6 to 8 o’clock position
2001 2008 2001 2008

Slope: -0.2dB / Yr Slope: 0.8dB / Yr (p<0.5%)

2001 2008

• Grayscale series shows expansion of superior nasal defect to a superior arcuate defect from 2001 to 2008
and mild inferotemporal sensitivity loss due to BRVO
• Signiicant (p < 1%) but slow MD worsening at 0.4 dB/year due to fast progression in affected superior
clusters (Cluster MD change 1.1 to 2.1 dB/year)
• Large (up to 30 dB) progression at 6 to 8 o’clock position in Polar Trend Analysis
• Rim thinning and RNFL loss spreading from 7 o’clock position towards 6 and 8 o'clock position
• Clear relationship between fundus and visual ield progression conirming glaucomatous progression
268 Chapter 13 | Clinical cases

12 EARLY TO MODERATE GLAUCOMA (PRIMARY OPEN-ANGLE GLAUCOMA)

PATIENT • 53-year-old male, no family history

• High IOP identiied during visit related to eye pain
IOP/VA corr • 25 mmHg/1.2 - 0.75 (sph), - 1.0 (cyl) x 90°
FUNDUS • 2002 Rim thinning at 1 to 2 o’clock position. Rim notching at 5 o’clock position.
RNFL loss at same positions. Optic disc hemorrhage at 6 o’clock position.
• 2008 Rim thinning from 1 to 6 o’clock position

MD Mean defect sLV Loss variance

0

0 1.1
0.6

0.2 2.5
0.1 S
30 20 10 N T
0.1 [dB]
I
0.0 0.2
15
0.0
-0.4
Floor effect Structural progression
25 15 (near absolute sensitivity loss)
2002 2008 2002 2008 suggested at
Slope: 0.5dB / Yr (p<0.5%) Slope: 0.1dB / Yr 5 o'clock position

DD Diffuse defect LD Local defect

0

0 2002 2008

25 15
2002 2008 2002 2008 Large progression at
Slope: 0.2dB / Yr Slope: 0.5dB / Yr (p<0.5%) 5 o’clock position

2002 2008

• Grayscale series shows expansion of inferior arcuate defect to superior nasal side from 2002 to 2008
• Signiicant (p < 1%) but slow MD worsening at 0.5 dB/year due to fast progression in affected superior
clusters (Cluster MD change up to 2.5 dB/year)
• Large (~28 dB) progression at 5 o’clock position in Polar Trend Analysis
• Rim thinning and RNFL loss spreading from 1 to 2 o'clock position towards 6 o'clock position
• Clear relationship between fundus and visual ield progression conirming glaucomatous progression
Glaucoma | Trend 269

13 EARLY TO MODERATE GLAUCOMA (NORMAL TENSION GLAUCOMA)

PATIENT • 51-year-old male, no family history

• Patient reported a blind spot in visual ield of left eye during reading and a visual
ield defect temporally near ixation upon ixation of distant objects
IOP/VA corr • 15 mmHg/1.0 - 6.0 (sph), - 1.25 (cyl) x 160°
FUNDUS • 2001 Small disc. RNFL loss (including papillomacular nerve iber) from 2 to 5 o’clock
position. Temporal alpha zone and beta zone peripapillary chorioretinal atrophy (PPA).
• 2004 Challenging to identify changes because of small disc and severe myopia

MD Mean defect sLV Loss variance

0

0 1.1
0.8

0.8 0.8
5.4 S
30 20 10
N T
3.3 [dB]
I
0.5 0.4
15

0.6
Very fast progression
0.6

25 15 in central visual Large progression suggested

2001 2002 2003 2004 2001 2002 2003 2004 field clusters at inferior temporal optic disc
Slope: 1.2dB / Yr (p<0.5%) Slope: 0.8dB / Yr (p<0.5%)

DD Diffuse defect LD Local defect

0

0 2001 2004

25 15
2001 2002 2003 2004 2001 2002 2003 2004
Slope: 0.5dB / Yr Slope: 1.0dB / Yr (p<0.5%)

2001 2004

• Grayscale series shows expansion of superior paracentral defect towards ixation from 2001 to 2004
• Signiicant (p < 1%) and fast MD worsening at 1.2 dB/year due to very fast progression in affected central
clusters (Cluster MD change 3.3 and 5.4 dB/year)
• Challenging to asses structural changes, but large (up to 30 dB) progression at 5 o’clock position in Polar
Trend Analysis corresponding with RNFL loss in fundus image suggests glaucomatous progression
• Relationship between fundus and visual ield progression conirming glaucomatous progression
270 Chapter 13 | Clinical cases

14 EARLY TO MODERATE GLAUCOMA (PRIMARY OPEN-ANGLE GLAUCOMA)

PATIENT • 74-year-old female

• Patient showed advanced disc damage at presentation
• Suboptimal IOP control under topical medication, but patient refused surgery
IOP/VA uncorr • 16 – 22 mmHg (28 mmHg pre-treatment)/1.0
OCT • 2008 Pathologically low peripapillary RNFLT in inferotemporal sectors
• 2013 Statistically signiicant further RNFLT decrease both infero- and superotemporally

FUNDUS • 2008 Advanced disc damage (C/D=0.95)

MD Mean defect sLV Loss variance Fast superior

0
paracentral
0 progression
2.6
2.5

0.4 -0.5
1.7 S
30 20 10 N T
0.7 [dB]
I
-0.1 0.2
15

0.0
MD change -0.0
25 1.0 dB/year 15
2013 2013
Slope: 1.0dB / Yr (p<0.5%) Slope: 0.4dB / Yr (p<0.5%)

DD Diffuse defect LD Local defect

0

0 2008 2013

No diffuse
progression
Significant
local
progression
25 15
2013 2013
Slope: 0.2dB / Yr Slope: 1.1dB / Yr (p<0.5%)

2008 2013

• Grayscale series shows progression of superior arcuate and both superior and inferior paracentral
defects from 2008 to 2013
• Local progression apparent from signiicant (p < 1%) sLV increase and LD worsening due to very fast
progression in superior arcuate and superior and inferior paracentral clusters (Cluster MD change up to
2.6 dB/year)
• Up to 30 dB progression at infero- and superotemporal test locations in Polar Trend Analysis spatially
related to further RNFLT loss between 2008 and 2013
• Relationship between OCT and visual ield progression conirming glaucomatous progression
Glaucoma | Trend 271

15 END-STAGE GLAUCOMA (EXFOLITATIVE GLAUCOMA)

PATIENT • 79-year-old female

• Patient presented with end-stage glaucoma, iltration surgery was performed with no
further medication during follow up
• Patient reported only minimal central visual ield worsening during follow-up
IOP/VA corr • 08–14 mmHg (43mmHg pre-treatment)/1.0 + 1.0 (sph)
OCT • 2008 Severe peripapillary RNFLT loss
• 2013 No change in the average peripapillary RNFLT
FUNDUS • 2008 C/D=0.99

MD Mean defect sLV Loss variance

0
0
-0.0
Floor effect 0.0

(MD > 20 dB, no progression)

-0.0 -0.0
1.4 S
15 30 20 10
N T
2.5 [dB]
I
-0.9 -0.0

-0.0
Fast superior
0.0
and inferior
35 15 paracentral
2013 2013
progression
Slope: 0,1dB / Yr Slope: -0,2dB / Yr (p<10%)

DD Diffuse defect LD Local defect

0

0 2008 2013
Floor effect
(DD > 20 dB, no progression)

25 15
2013 2013
Slope: -0,0dB / Yr Slope: 0,0dB / Yr

2008 2013

• Grayscale series shows very dense visual ield loss with little remaining sensitivity in macula
• MD appears stable, but cannot be interpreted for progression because of loor effect (exceeding perimeter’s
measurement range)
• Signiicant (p < 1%) superior and inferior paracentral progression (Cluster MD change 1.4 and 2.5 dB/year)
• 12 to 25 dB progression at 8 to 10 o’clock position (papillomacular bundle) in Polar Trend Analysis not
apparent in OCT results due to the loor effect of OCT in end-stage glaucoma
• Polar and Cluster Trend Analysis indicate late-stage glaucomatous progression
272 Chapter 13 | Clinical cases

16 CEREBRAL INFARCTION (BILATERAL)

PATIENT • 65-year-old male, no family history

• Patient experienced occipital headache and optic agnosia of name, letters, etc.
• Diagnosed with cerebral infarction in left temporal lobe
• Previous central serous chorioretinopathy in left eye

Demo John, 1933/01/01 (65yrs)

Left eye (OS) / 1999/07/12 / 11:36:23
Seven-in-One

Grayscale (CO) Values

26.3 24 0.4
-0.1 25.7
95%..100%
24 27 26 1
83%...94%
71%...82% 26
25 26
59%...70%
27 24 28 5
47%...58% 27 28
35%...46% 30 29 1
23
30 24 2 1
23%...34% 30 31 21 18 1
11%...22% 29 31 27
29 30
0%...10% 27 27 27 26
29 30

27 28 30 28 28 24
-1.0 7.9 28.4 19.0
29 26

Comparisons Corrected comparisons Defect curve

Rank
+ + 1 74

-5
+ + + 23 + + + 23

+ + 0
5%
+ + + +
+ + + 23 + + + 23 5
+ + + + Defect (dB) 95%
+ + 30 + + 30 10
9 9
+ 7 29 28 + 7 29 28
+ + 9 11 26 + + 9 10 26 15
+ + + + + +
+ + + +
Sensitivity
+ + loss + + + + + + 20

at fixation + + + +
25
+ + + + + + + + + + + +
Diffuse defect [dB]: -1.1
+ + + + Vertical drop
characteristic for
Probabilities Corrected probabilities quadrantanopia

p>5
p<5
p<2
p<1
p < 0,5

Programs: G Standard White/White / Normal Questions / repetitions: 409 / 2 30°

Parameters: 4 / 1000 asb III 100 ms Duration: 15:54 MS [dB]: 18.3
Catch trials: 0/20 (0%) +, 4/21 (19%) - RF: 9.7 MD [< 2.0 dB]: 8.4
Refraction S/C/A: +0.75/-1.5/90 VA: 0.4 sLV [< 2.5 dB]: 12.4
Pupil [mm]: 6.4 IOP [mmHg]: 14 CsLV [dB]: 12.5
SF [dB]: 1.5
Comment:
Classification:

OCTOPUS® OCTOPUS 101

N euro | S ingle field 2 73

IOP/VA corr • OD 19 mmHg/ 1.0 + 0.5 (sph), – 2.0 (cyl) x 100°; OS 20 mmHg/ 0.4 – 1.5 (cyl) x 90°
FUNDUS • No abnormality

Demo John, 1933/01/01 (65yrs)

Right eye (OD) / 1999/07/12 / 11:00:42
Seven-in-One

Grayscale (CO) Values

26.3 25 2.0
-0.1 24.1
95%..100%
26 23 24
83%...94%
71%...82% 24 1
25 27
59%...70%
28 28 25 3
47%...58% 27 27 27 28
35%...46% 28 30 1
29
29 31 20
23%...34% 28 29 29 26 21 18
11%...22% 30 24 13
30 27
0%...10% 29 28 25 24
29 28

27 28 28 25 28 25
-1.4 6.1 28.3 21.4
28 25

Comparisons Corrected comparisons Defect curve

Rank
+ + 1 74

+ + + + + + -5

+ 26 + 25 0
5%
+ + + +
+ + + 22 + + + 22 5
Defect (dB)

+ + + + + + + +
+ + 30 + + 29 10 95%
+ +
+ + 11 + + 11
+ + + + 9 9 + + + + 9 9 15
+ 5 13 + 5 13
+ + + +
+ + + + + + + + 20
+ + + +
25
+ + + + + + + + + + + +
Diffuse defect [dB]: -1.1
+ + + +

Probabilities Corrected probabilities

p>5
p<5
p<2
p<1
p < 0,5

Programs: G Standard White/White / Normal Questions / repetitions: 424 / 0 30°

Parameters: 4 / 1000 asb III 100 ms Duration: 16:01 MS [dB]: 19.9
Catch trials: 0/21 (0%) +, 6/22 (27%) - RF: 13.9 MD [< 2.0 dB]: 6.8
Refraction S/C/A: +0.5/-2.0/90 VA: 1.0 sLV [< 2.5 dB]: 11.3
Pupil [mm]: 6.0 IOP [mmHg]: 14 CsLV [dB]: 11.3
SF [dB]: 2.0
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• Superior homonymous quadrantanopia sparing ixation on right side of vertical meridian due to cerebral
infarction in left temporal lobe
• Signiicant sensitivity loss at ixation in left eye due to previous central serous chorioretinopathy with
decrease in visual acuity (0.4)
274 Chapter 13 | Clinical cases

17 LEBER HEREDITARY OPTIC NEUROPATHY (BILATERAL)

PATIENT • 31-year-old male, no family history

• Patient reported decreased visual acuity in right eye
• Patient diagnosed with central serous chorioretinopathy and retinal hemorrhage
• After referral, patient diagnosed with optic neuropathy based on MRI indings
• Patient diagnosed with Leber hereditary optic neuropathy based on maternal
mitochondrial DNA test

Demo John, 1973/01/01 (31yrs)

Left eye (OS) / 2004/10/21 / 12:51:41
Seven-in-One

Grayscale (CO) Values

16 17
8.5 18.7 19.3 8.8
95%..100%
21 15 14 7 20 13
83%...94%
71%...82% 18 22 21 22 10 12 9 14

59%...70% 22 21 24 26 22 13 2 1 17 16
47%...58%
22 24 23 19 3 1 1 15
35%...46%
23%...34% 22 22 22 19 4
11%...22%
22 27 25 28 11 2
0%...10%
21 23 21 20 20 5 12 10

19 24 24 22 18 15
7.8 20.5 21.4 8.0
20 21 23 24

Comparisons Corrected comparisons Defect curve

9 7 + + Rank
120 105 90 75 60 1 74

6 11 13 19 6 12 + + 5 12 + 5 -5
135 45
10 6 7 6 19 16 19 12 + + + + 11 8 11 + 0
5%
150 30 6 7 5 + 8 17 28 28 10 9 + + + + + 9 20 20 + + 5

6 5 7 13 29 31 27 11 + + + 5 21 23 19 + Defect (dB)
10 95%
165 15
7 7 9 13 23 + + + 5 15
15
6 + 5 + 20 29 + + + + 13 21
180 10 30 40 50 60 70 80 90 0 20
8 6 9 10 10 24 16 17 + + + + + 16 9 9
25
10 5 5 7 10 11 + + + + + + Diffuse defect [dB]: -1.1
195 345
8 7 5 + + + + +

210 330 Probabilities Corrected probabilities

225 315

240 255 270 285 300

p>5
p<5
V4e p<2
p<1
I4e p < 0,5

I3e
I3a Programs: 32 Standard White/White / Normal Questions / repetitions: 585 / 0 30°
Parameters: 4 / 1000 asb III 100 ms Duration: 19:20 MS [dB]: 14.2
Catch trials: 0/29 (0%) +, 4/30 (13%) - RF: 6.7 MD [< 2.0 dB]: 14.0
Refraction S/C/A: // VA: sLV [< 2.5 dB]: 9.2
Pupil [mm]: 6.0 IOP [mmHg]: CsLV [dB]: 9.2
SF [dB]: 1.9
Comment:
Classification:

OCTOPUS® OCTOPUS 101

N euro | S ingle field 2 75

IOP/VA corr • OD 10 mmHg/ 10 cm, inger counting; OS 10 mmHg/ 30 cm, hand motion
FUNDUS • Pale optic discs in both eyes
CENTRAL CFF • OD 32 Hz; OS 42 Hz

Demo John, 1973/01/01 (31yrs)

Right eye (OD) / 2004/10/21 / 13:17:49
Seven-in-One

Grayscale (CO) Values

23 18 20 19
4.7 12.6 22.7 15.2
95%..100%
22 24 23 25 24 18
83%...94%
71%...82% 22 24 24 26 22 23 19 21

59%...70% 21 24 24 26 23 22 24 1 20
47%...58%
22 23 25 22 20 4 15
35%...46%
23%...34% 23 22 25 24 22 7 1 19

11%...22%
22 23 22 23 20 22 24 24 18 23
0%...10%
23 25 24 23 21 23 23 25

21 25 23 22 23 24
5.6 10.2 22.9 19.1
24 25 25 24

Comparisons Corrected comparisons Defect curve

+ 7 5 6 + + + + Rank
1 74
120 105 90 75 60
+ + + + + 9 + + + + + + -5
135 45
+ + + + 6 5 9 7 + + + + + + + + 0
5%
+ + 5 + 7 8 5 27 8 + + + + + + + 22 + 5
150 30
Defect (dB)

+ 5 5 10 12 28 13 + + + + 7 22 8 10 95%
165 15
+ 6 6 7 11 25 28 10 + + + + 6 20 23 5
15
+ 5 7 8 11 9 6 6 11 5 + + + + 5 + + + 6 +
20
180 10 30 40 50 60 70 80 90 0
+ + 5 7 9 7 6 + + + + + + + + +
25
5 + 6 7 6 5 + + + + + + Diffuse defect [dB]: -1.1
195 345
+ + + + + + + +

Probabilities Corrected probabilities

210 330

225 315

240 255 270 285 300

p>5
p<5
p<2 V4e
p<1
p < 0,5 I4e
I3e

Programs: 32 Standard White/White / Normal Questions / repetitions: 572 / 0 30° I3c

Parameters: 4 / 1000 asb III 100 ms Duration: 18:29
I2e
MS [dB]: 20.0
Catch trials: 0/29 (0%) +, 3/29 (10%) - RF: 5.1 MD [< 2.0 dB]: 8.2
Refraction S/C/A: // VA: sLV [< 2.5 dB]: 7.6
Pupil [mm]: 6.2 IOP [mmHg]: CsLV [dB]: 7.5
SF [dB]: 1.8
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• Dense sensitivity loss in center of both eyes

• Additional inferior nasal visual ield loss from 20 to 50°
• Asymmetrical visual ield defect, central and peripheral scotomas more severe in left eye
276 Chapter 13 | Clinical cases

18 BILATERAL OPTIC NEURITIS (MULTIPLE SCLEROSIS)

PATIENT • 25-year-old female, no family history

• Patient reported dificulty in seeing for two weeks

Demo Jane, 1975/01/01 (25yrs)

Left eye (OS) / 2001/11/30 / 14:19:18
Seven-in-One

Grayscale (CO) Values

22 13 16 19
6.7 4.1 21.4 23.8
95%..100%
16 21 23 22 26 24
83%...94%
71%...82% 18 24 22 25 25 24 25 23

59%...70% 26 22 23 23 23 28 25 25 23 23
47%...58%
20 20 24 26 29 27 25 25 22
35%...46%
23%...34% 24 26 12 9 28 27 28 24 22
11%...22%
22 20 14 14 13 26 26 25 24 22
0%...10%
15 18 24 18 27 26 24 24

21 18 20 25 26 25
11.8 4.1 17.8 24.8
20 18 24 22

Comparisons Corrected comparisons Defect curve

+ 12 9 6 + 7 + + Rank
120 105 90 75 60 1 74

11 6 + 5 + + 6 + + + + + -5
135 45
10 + 7 + + + + + 5 + + + + + + + 0
5%
150 30
+ 6 6 7 8 + 6 + 5 + + + + + + + + + + + 5

8 9 7 7 + 5 5 + 5 + + + + + + + + + Defect (dB) 10 95%

165 15
5 + 20 24 5 5 + 5 6 + + 15 18 + + + + +
15
7 9 17 17 19 5 5 5 5 5 + + 11 12 14 + + + + +
180 10 30 40 50 60 70 80 90 0 20
14 12 7 12 + + 5 + 9 7 + 7 + + + +
25
8 11 10 + + + + 6 5 + + + Diffuse defect [dB]: -1.1
195 345
9 10 + 5 + 5 + +

210 330 Probabilities Corrected probabilities

225 315

240 255 270 285 300

p>5
p<5
V4e p<2
p<1
I4e p < 0,5

I3e
I3b Programs: 32 Standard White/White / Normal Questions / repetitions: 627 / 2 30°
Parameters: 4 / 1000 asb III 100 ms Duration: 20:51
I2e Catch trials: 0/31 (0%) +, 1/32 (3%) - RF: 1.5
MS [dB]:
MD [< 2.0 dB]:
22.0
6.6
Refraction S/C/A: +0.25/-0.5/80 VA: 1.0 sLV [< 2.5 dB]: 4.4
I2b Pupil [mm]: 6.3 IOP [mmHg]: 11 CsLV [dB]: 3.9
SF [dB]: 2.6
Comment:
I1e Classification:

OCTOPUS® OCTOPUS 101

N euro | S ingle field 2 7 7

IOP/VA corr • OD 13 mmHg/ 0.7 + 0.25 (sph), – 1.0 (cyl) x 85°

OS 11mmHg/ 1.0 + 0.25 (sph), – 0.5 (cyl) x 80°
FUNDUS • No abnormality
CFF • OD 34 Hz; OS 44 Hz
MRI • Demyelinated plaque at optic chiasm

Demo Jane, 1975/01/01 (25yrs)

Right eye (OD) / 2001/11/30 / 14:45:35
Seven-in-One

Grayscale (CO) Values

26 16 24 25
2.1 2.0 25.8 26.2
95%..100%
22 27 24 23 26 27
83%...94%
71%...82% 26 27 25 26 23 26 25 27

59%...70% 26 26 27 28 29 29 30 29 26 26
47%...58%
25 27 28 30 29 28 27 27 28
35%...46%
23%...34% 27 28 27 30 19 26 26 29 29
11%...22%
26 27 27 27 15 18 20 15 27 28
0%...10%
24 27 25 26 7 15 23 23

25 29 26 19 20 20
3.6 8.3 25.3 21.3
26 24 21 23

Comparisons Corrected comparisons Defect curve

+ 9 + + + 7 + + Rank
1 74 120 105 90 75 60
+ + + + + + + + + + + + -5
135 45
+ + + + 6 + + + + + + + + + + + 0
5%
150 30
+ + + + + + + + + + + + + + + + + + + + 5
Defect (dB)

+ + + + + 5 + + + + + + + + + + + + 10 95%
165 15
+ + + + 14 7 6 + + + + + + 12 + + + +
15
+ + + + 16 14 11 16 + + + + + + 14 12 9 13 + +
20 180 10 30 40 50 60 70 80 90 0
+ + + 5 23 16 7 6 + + + + 21 13 5 +
25
+ + + 11 9 9 + + + 9 7 7 Diffuse defect [dB]: -1.1
195 345
+ + 7 6 + + 5 +

Probabilities Corrected probabilities 210 330

225 315

240 255 270

Intact
285
peripheral
300
visual field
p>5
p<5
p<2 V4e
p<1
p < 0,5 I4e
I3e

Programs: 32 Standard White/White / Normal Questions / repetitions: 568 / 4 30°

I3b
Parameters: 4 / 1000 asb III 100 ms Duration: 19:38
Catch trials: 0/28 (0%) +, 2/29 (7%) - RF: 3.5
MS [dB]:
MD [< 2.0 dB]:
24.7
3.9
I2e
Refraction S/C/A: +0.25/-1.0/85 VA: 0.7 sLV [< 2.5 dB]: 4.7
Pupil [mm]: IOP [mmHg]: 13 CsLV [dB]: 4.5 I2b
SF [dB]: 1.9
Comment:
Classification: I1e
I1a
OCTOPUS® OCTOPUS 101

• Sensitivity loss on lower temporal side of vertical meridian in both eyes (i.e., mild bitemporal hemianopia)
• MRI shows demyelinated plaque, thus bitemporal hemianopia is attributed to multiple sclerosis at optic
chiasm
278 Chapter 13 | Clinical cases

19 TUBERCULUM SELLAE MENINGIOMA (BILATERAL)

PATIENT • 64-year-old male, no family history

• Patient reported dificulty in reading books and newspaper

Demo John, 1941/01/01 (64yrs)

Left eye (OS) / 2005/10/12 / 12:52:19
Seven-in-One

Grayscale (CO) Values

18 18
24.7 1.6 0.9 23.7
95%..100%
1 15 24 23 19
83%...94%
71%...82% 2 22 24 24 21

59%...70% 27 25 25 23 22
47%...58%
30 30 27 28 25
35%...46%
23%...34% 30 27 29 27 26

11%...22%
28 27 27 25 25
0%...10%
1 27 25 24 25

9 26 24 21
26.5 0.9 0.6 25.4
2 22 23

Comparisons Corrected comparisons Defect curve

5 + + + Rank
120 105 90 75 60 1 74

24 10 + + + 21 7 + + + -5
135 45
24 5 + + + 22 + + + + 0
5%
150 30
V4e + + + + + + + + + + 5

Defect (dB)
+ + + + + + + + + + 10 95%
165 15
I4e + + + + + + + + + + 15

+ + + + + + + + + +
I3e
180 10 30 40 50 60 70 80 90 0
27 + + + + 25 + + + +
20

25

I2e
195 345
18 + + + 16 + + + Diffuse defect [dB]: -1.1

24 + + 22 + +

I1e210 330 Probabilities Corrected probabilities

225 315

240 255 270 285 300

Absolute defect p>5

stopping at p<5
vertical midline p<2
p<1
p < 0,5

Programs: 32 Standard White/White / Normal Questions / repetitions: 415 / 0 30°

Parameters: 4 / 1000 asb III 100 ms Duration: 16:34 MS [dB]: 13.0
Catch trials: 0/21 (0%) +, 7/21 (33%) - RF: 16.6 MD [< 2.0 dB]: 13.1
Refraction S/C/A: +1.0/-1.0/100 VA: 1.0 sLV [< 2.5 dB]: 12.4
Pupil [mm]: 5.7 IOP [mmHg]: 15 CsLV [dB]: 12.4
SF [dB]: 1.4
Comment:
Classification:

OCTOPUS® OCTOPUS 101

N euro | S ingle field 2 79

IOP/VA corr • OD 12 mmHg/0.15 – 2.0 (sph)

OS 13 mmHg/1.2 – 1.5 (sph), – 1.0 (cyl) x 100°
FUNDUS • Pale optic disc with slight cupping
• Slight bending of blood vessels
CFF • OD 25 Hz; OS 40 Hz
MRI • Meningioma in tuberculum sellae

Demo John, 1941/01/01 (64yrs)

Right eye (OD) / 2005/10/12 / 13:14:55
Seven-in-One

Grayscale (CO) Values

25.3 25.6 0.1 0.0

95%..100%
83%...94%
71%...82%
59%...70%
47%...58%
2
35%...46%
23%...34% 16 14 23 26 24

11%...22%
20 19 18 24 22
0%...10%
18 15 18 19

8 13 12
9.8 27.1 16.6 0.0
4 7

Comparisons Corrected comparisons Defect curve

Rank
1 74 120 105 90 75 60
-5
135 45
0
5%
150 30
5
Defect (dB)

28 9 95%
10
165 15
9 12 6 + 7 + + + + +
15
+ 7 9 5 7 + + + + +
20
180 10 30 40 50 60 70 80 90 0
7 11 9 9 + + + +
25
16 13 15 + + + Diffuse defect [dB]: -1.1
195 345
20 19 + +

Probabilities Corrected probabilities 210 330

225 315

240 255 270 285 300

p>5
p<5
p<2 V4e
p<1
p < 0,5 I4e
I3e

Programs: 32 Standard White/White / Normal Questions / repetitions: 363 / 0 30°

I2e
Parameters: 4 / 1000 asb III 100 ms Duration: 15:20
Catch trials: 0/18 (0%) +, 8/19 (42%) - RF: 21.6
MS [dB]:
MD [< 2.0 dB]:
4.3
21.8 I1e
Refraction S/C/A: +0.5// VA: 0.15 sLV [< 2.5 dB]: 7.8
Pupil [mm]: 6.0 IOP [mmHg]: 13 CsLV [dB]: 7.7
SF [dB]: 2.1
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• Complete sensitivity loss (heterononymous hemianopia) temporally of vertical meridian

• Additional absolute defect in superior nasal quadrant of right eye
280 Chapter 13 | Clinical cases

20 AGE-RELATED MACULAR DEGENERATION

PATIENT • 64-year-old male, no family history

• Patient reported decreased visual acuity in left eye
IOP/VA corr • 13 mmHg/ 0.2 – 1.75 (sph), – 0.75 (cyl) x 80°
FUNDUS • Exudative age-related macular degeneration in macula area

Demo John, 1942/01/01 (64yrs)

Left eye (OS) / 2006/09/28 / 14:38:48
Seven-in-One

Greyscale (CO) Values

15.8 14.6
13.8 15.2
95%..100% 29 28

83%...94% 28 28 25 29
71%...82% 30 23 17 27
59%...70% 23 17 2 10 11 30
47%...58% 25 11 8 2 9 7 4 25
25 1012 4 9 1114 16
35%...46% 21 6 7 9 9 6 5 4
7
18 20 1 4 11 6 7 18
23%...34% 24 11 9 13 12 11 3 26
26 6 16 13 9 1811 31
11%...22% 22 25 13 11 27 30
0%...10%
27 24 25 29

27 27 28 28
12.7 12.0 27 30
17.4 18.3

Comparisons Corrected comparisons Defect curve

Rank
1 74
+ + + +
-5
+ + + + + + + +
0
+ 6 12 + + + 8 + 5%

6 12 2820 19 + + 8 2316 15 + 5
Defect (dB)

+ 192329222327 + + 151824181922 +
5 201927232017 14 + 161523181513 9 95%
10252523 23252727 5 20201819212222 10
25
1311302821262413 21
8 7 2624172220 9
6 202219192128 5 + 161815151624 + 15
+ 251519221320 + + 20101418 9 15 +
7 5 1820 + + + + 1316 + +
20
+ 6 5 + + + + +

+ + + + + + + + 25
Diffuse defect [dB]: -1.1
+ + + +

Probabilities Corrected probabilities

p>5
p<5
p<2
p<1
p < 0,5

M-pattern

Programs: M Standard White/White / Normal Questions / repetitions: 759 / 0 12°

Parameters: 4 / 1000 asb III 100 ms Duration: 23:03 MS [dB]: 16.4
Catch trials: 0/38 (0%) +, 2/38 (5%) - RF: 2.6 MD [< 2.0 dB]: 13.6
Refraction S/C/A: -1.0// VA: 0.3 sLV [< 2.5 dB]: 10.1
Pupil [mm]: 6.1 IOP [mmHg]: 19 CsLV [dB]: 10.2
SF [dB]: 3.1
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• M-pattern (10°) used for a high resolution of the macula

• Dense visual ield loss within central 5° of macula, no visual ield loss from 6° to 10°
R etina | S ingle field 2 8 1

21 BRANCH CENTRAL RETINAL ARTERY OCCLUSION

PATIENT • 51-year-old female, no family history

• Patient reported sudden loss of vision in superior visual ield of left eye
IOP/VA corr • 14 mmHg/ 1.0 – 4.0 (sph), + 0.75 (cyl) x 80°
FUNDUS • Ischemia-induced retinal edema in area of blood vessels caused by occlusion of the
downward branch of the central retinal artery

Demo Jane, 1956/01/01 (51yrs)

Left eye (OS) / 2007/05/16 / 11:37:22
Seven-in-One

Greyscale (CO) Values

11.1 20.2
19.3 10.3
95%..100% 11 6

83%...94% 19 23 22 18
71%...82% 12 2 20 23
59%...70% 22 1 20 23
47%...58% 20 1 2 4 13 25
7 15 9 8 32 2529 29
35%...46% 8 2725 16 29 3230 28
33
26 3329 33 33 2529 31
23%...34% 27 3131 33 31 3232 30
31 3333 29 30 3232 31
11%...22% 26 32 33 32 31 31
0%...10%
32 31 32 30

30 30 29 28
0.5 0.8 29 29
30.4 30.2

Comparisons Corrected comparisons Defect curve

Rank
1 74 120 105 90 75 60
18 22 16 21
-5 135 45
10 6 7 11 9 + 6 9
0
18 28 10 6 16 27 9 5 5%
150 30
7 30 11 7 6 29 9 5 5
Defect (dB)

10 3029 2718 5 9 2928 2617 +

24 162324 + 7 + + 22 152223 + 5 + + 95%
24 5 8 17++ + + + 22 + 6 15++ + + + 10 165 15
5 + + ++ 8 + + + + + ++ 7 + +
+ + + ++ + + + + + + ++ + + +
+ + + ++ + + + + + + ++ + + + 15
+ + ++ + + + + ++ + +
20 180 10 30 40 50 60 70 80 90 0
+ + + + + + + +

+ + + + + + + + 25

+ + + + Diffuse defect [dB]: -1.1

195 345

Probabilities Corrected probabilities 210 330

225 315

240 255 270 285 300

p>5
p<5
p<2 V4e
p<1
p < 0,5 I4e
I3e
I2e
Programs: M Standard White/White / Normal Questions / repetitions: 703 / 0 12°
Parameters:
Catch trials:
4 / 1000 asb III 100 ms
0/35 (0%) +, 3/36 (8%) -
Duration:
RF:
21:19
4.2
MS [dB]: 23.1 I1e
MD [< 2.0 dB]: 7.7
Refraction S/C/A: -2.5/-0.75/80 VA: 1.0 sLV [< 2.5 dB]: 10.3
Pupil [mm]: IOP [mmHg]: CsLV [dB]: 10.1
SF [dB]: 4.0
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• M-pattern (10°) used for a high resolution of the macula

• Dense to absolute visual ield loss in superior visual ield corresponding with ischemic region of downward
retinal artery
• Fixation is spared, corrected visual acuity of 1.0 is maintained
• Kinetic perimetry shows absolute defect outside 10° nasally
282 Chapter 13 | Clinical cases

22 MACULAR HOLE

PATIENT • 67-year-old female, no family history

• Patient reported distorted vision in right eye
IOP/VA corr • 12 mmHg/ 0.2 – 1.5 (sph), – 2.5 (cyl) x 80°
FUNDUS • Macular hole with luid cuff in surrounding region

Demo Jane, 1939/01/01 (67yrs)

Right eye (OD) / 2006/07/31 / 13:23:40
Seven-in-One

Greyscale (CO) Values

25.6 25.1
4.0 4.3
95%..100% 22 25

83%...94% 22 28 27 27
71%...82% 27 27 27 26
59%...70% 26 29 25 25 27 27
47%...58% 29 2825 26 23 2527 30
29 2526 2420 2425 29
35%...46% 30 2724 17 20 252226
16
282423 21 18 1824 28
23%...34% 29 2627 2423 2526 28
28 2526 25 23 2727 28
11%...22% 28 30 28 25 30 26
0%...10%
28 30 29 28

28 28 27 26
3.6 4.6 28 25
26.4 25.3

Comparisons Corrected comparisons Defect curve

Rank
1 74
5 + + +
-5
6 + + + + + + +
0
+ + + + + + + + 5%

+ + 55 + + + + ++ + + 5
Defect (dB)

+ + 5 57 5 + + + + + +5 + + +
+ 6 5 711 7 5 + + + + 58 5 + + 95%
+ + 7 1512 7 9 5 + + 5 13 9 + 6 + 10
+ 7 16
9 111413 7 + + 5 6 814
1211 5 +
+ 5 5 79 6 5 + + + + 56 + + +
+ 5 5 68 + + + + + + +6 + + + 15
+ + +5 + + + + ++ + +
20
+ + + + + + + +

+ + + + + + + + 25

+ + + + Diffuse defect [dB]: -1.1

Probabilities Corrected probabilities

Signficant
foveal defect
at p < 0.5% p>5
p<5
p<2
p<1
p < 0,5

M-pattern

Programs: M Standard White/White / Normal Questions / repetitions: 611 / 0 12°

Parameters: 4 / 1000 asb III 100 ms Duration: 18:13 MS [dB]: 25.5
Catch trials: 1/30 (3%) +, 2/31 (6%) - RF: 4.9 MD [< 2.0 dB]: 4.3
Refraction S/C/A: +1.0/-2.5/80 VA: 0.2 sLV [< 2.5 dB]: 3.8
Pupil [mm]: IOP [mmHg]: 14 CsLV [dB]: 3.6
SF [dB]: 1.9
Comment:
Classification:

OCTOPUS® OCTOPUS 101

• M-pattern (10°) used for a high resolution of the macula

• Signiicant visual ield loss in the central fovea leading to decreased visual acuity (0.2) due to macular hole
R etina | S ingle field 2 8 3

23 BRANCH CENTRAL RETINAL VEIN OCCLUSION

PATIENT • 76-year-old male, no family history

• Patient reported decreased visual acuity in left eye, blurred and double vision
IOP/VA corr • 10 mmHg/ 0.2 + 3.75 (sph), – 2.0 (cyl) x 170°
FUNDUS • Retinal hemorrhage and soft exudate along RNFL in lower retinal arcade

Demo John, 1928/01/01 (76yrs)

Left eye (OS) / 2004/03/24 / 15:44:51
Seven-in-One

Greyscale (CO) Values

16.7 16 16 16.7
8.7 8.7
95%..100%
18 18 12 18 15 17
83%...94%
71%...82% 14 14
23 21 12 16
59%...70%
21 14 14 15 18
47%...58% 20 11 19 20 18 15
35%...46% 24 11 16 25
17
23%...34% 20 22 24 24
22 24 24 24 10 18
11%...22% 20 24 23
23 23
0%...10% 23 22 24 22
21 22

20 22 22 20 24 22
5.1 4.8 21.6 21.4
22 22

Comparisons Corrected comparisons Defect curve

Rank
7 6 + + 1 74

5 6 12 6 8 6 + + 6 + + + -5

11 12 6 7 0
5%
+ 5 13 8 + + 8 +
+ 13 14 12 10 + 7 8 7 + 5
Defect (dB)

5 17 10 7 7 8 + 12 + + + +
+ 18 14 + + 13 9 + 10 95%
14 9
8 8 6 5 + + + +
+ 5 5 + 16 6 + + + + 11 + 15
5 + 5 5 5 + + + + +
+ +
7 5
+ + + +
+ +
+ + 20
Diffuse &
25 local defect
5 + 5 6 + + + + + + + +
Diffuse defect [dB]: -1.1
+ + + +

Probabilities Corrected probabilities

p>5
p<5
p<2
p<1
p < 0,5

Programs: G Standard White/White / Normal Questions / repetitions: 474 / 1 30°

Parameters: 4 / 1000 asb III 100 ms Duration: 16:31 MS [dB]: 19.1
Catch trials: 1/24 (4%) +, 0/24 (0%) - RF: 2.0 MD [< 2.0 dB]: 6.9
Refraction S/C/A: +7.0/-2.0/170 VA: 0.2 sLV [< 2.5 dB]: 4.1
Pupil [mm]: 7.2 IOP [mmHg]: CsLV [dB]: 4.0

Comment:
Very reliable test SF [dB]: 2.1

Classification:

OCTOPUS® OCTOPUS 101

• Sensitivity loss in superior visual ield corresponding with inferior retinal hemorrhage
• Diffuse visual ield defect associated with poor visual acuity (0.2)
• Signiicant local visual ield loss in superior paracentral area due to macular edema
Index 285

INDEX
07 pattern 70, 72-73 Comparisons 103-106, 149-151
10-2 pattern 72, 244 constricted visual ield 60-61, 65, 148, 271
1-level test (1 LT) 91-92 Corrected Cluster Analysis 116, 118, 143-144,
24-2 pattern 64, 244 152-155
2-level test (2 LT) 94-95 Corrected Cluster Trend Analysis (CCTA) 166-167,
32/30-2 pattern 64, 244 183-186
Corrected Comparisons 115-117, 143-144, 149-151
A Corrected Grayscale (CO) 116 - 117, 149 - 151
ability testing 74-78 Corrected Probabilities 116, 118, 143-148
abnormal visual ield 11, 19, 145-148 Corrected square root of Loss Variance (CsLV) 119,
absolute defect 101-102, 261 121
age-related macular degeneration (AMD) 70-71, 280 critical fusion frequency (CFF) 198-199
altitudinal defect 60-61 cupola perimeter 214-215, 236, 243
apostilb (asb) 14-15
arcuate defect 60-61, 259, 265-268, 270 D
artifactual visual ields, see untrustworthy visual ield D pattern 73
asb, see apostilb data import 239-242
automated kinetic perimetry 230-231 dB, see decibel
DD (diffuse defect) 115-118, 121-122, 179, 181-182
B DD Trend Analysis 166-167, 179, 181-182
B pattern 69 decibel (dB) 14-15
background 47 Defect Curve 109-110, 141-143
background luminance 47, 200, 236 defect, see sensitivity loss
baseline tests 250-251 deviation from normal, see sensitivity loss
beeping sound 39 diabetic retinopathy 70-71, 73
binocular visual ield 8-9 diffuse defect 60-61, 100, 115-118, 140-144,
blepharoptosis, see ptosis 178-182
blind spot 69, 90-91, 205 disability testing 78
blue-on-yellow perimetry, see SWAP driving license test 74-76
drug-induced maculopathy 70-71
C dynamic range 195, 201-202
caecocentral defect 68 dynamic strategy 83, 85-86
candela per m2 (cd/m2) 14-15
cataract 140-141, 181, 260 E
catch trials 123-124 Esterman test 74-75
cd/m2, see candela per m2 examination parameters
central defect 68, 70-71, 280, 282 ixed 47-48
chiasmal defect, see heteronymous defect patient-speciic 48-57
Cluster Analysis 110-113, 152-155 exfolitative glaucoma 271
cluster defect 146-147, 152-155, 183 eye patch 31
Cluster Trend Analysis (CTA) 166-167, 183-186 EyeSuite Progression Analysis 166-190
286 Index

F Grayscale
F pattern 69 of Comparisons 105-106, 149-151
false negative answers 124-125, 138-139, 225, 248 of Corrected Comparisons 116 - 117, 149 - 151
false positive answers 45, 123, 125, 138-139, 177, of Values 102, 106, 245
224-225, 247 Guided Progression Analysis (GPA) 250-252
fatigue effect 38
ixation 34-36 H
ixation loss 35, 39, 45, 248 Heijl-Krakau blind spot monitoring 248
ixation targets 34 hemianopia 67-68, 206, 231, 278
ixed examination parameters 47-48 Hertz (Hz) 198-199
licker perimetry 52-53, 198-199 heteronymous defect 67-68, 278-279
loor effect 171, 175, 184, 195, 201-201,268, 271 HFA, see Humphrey Field Analyzer
luctuation 20-22, 136-140, 172-173, 243 hill of vision 10-11, 13, 16, 18-19, 207-210
frequency-of-seeing curve 21-22 homonymous defect 67-68, 272-273
function-speciic perimetry 52-53, 193-196 Humphrey Field Analyzer 235-252
hydroxychloroquine, see drug-induced maculopathy
G
G pattern 39, 62-63, 65 I
gaze tracker 248 intensity, see luminance
glaucoma isopter 207-210, 219-223
advanced stage 65, 148, 265, 271
altitudinal defect 60-61 K
arcuate defect 60-61, 259, 265-268, 270 kinetic perimetry 48-51, 205-232
constricted visual ield 60-61, 65, 148, 271
diffuse defect 60-61 L
early stage 153-154, 158, 257-262, 266-270 LD (local defect) 122, 180-182
exfoliative 271 LD Trend Analysis 166-167, 180-182
moderate stage 263-264, 266-270 learning effect 37-38, 243
nasal step 60-61, 143-144, 258, 260, 266-267 lens rim artifact 43, 45
normal tension 257-258, 261, 263, 267, 269 lens, see trial lens
paracentral defect 60-61, 258-259, 261, 269-270 lid artifact, see also ptosis 43-44, 77, 177
partial arcuate defect 60-61, 262-263 linear regression analysis 172
primary open-angle 259, 262, 264-266, 268, 270 local defect 100, 115-118, 140-143, 178-182
progression 181-182, 185-186, 190, 266-271 local sensitivity loss, see local defect
temporal wedge defect 60-61 low vision 53, 65, 86-87, 148, 265, 201-202, 212,
test patterns 62-66 271
typical defects 60-61 low vision strategy 83, 86-87
Glaucoma Hemiield Test (GHT) 247-249 luminance
global indices 119-122 background 47, 200, 236
Global Trend Analysis (GTA) 166-167 general 14-15, 47-48
Goldmann maximum stimulus intensity 47-48, 236-237
perimeter 214-215 stimulus intensity 14-15, 47-48, 217-218
stimulus intensities 217-218
stimulus size 52, 216-217 M
GPA, see Guided Progression Analysis M pattern 65, 71-72, 280, 282
G-Peripheral pattern 65-66 macular hole 282
Index 287

manual kinetic perimetry 230 patient instructions 29-30, 199, 201

maximum stimulus luminance 47-48, 236-237 patient monitoring 35-36
MD Trend Analysis 166-167, 174-176, 178-179 patient positioning 31-34
Mean Defect (MD) 119, 159-160, 168, 174-176, patient-speciic examination parameters 48-57
178-179 Pattern Deviation 245-246
Mean Deviation (MD) 247 Pattern Standard Deviation (PSD) 247
Mean Sensitivity (MS) 119 pattern, see test pattern
monocular visual ield 8-9 perimeter
cupola perimeter 214-215, 236, 243
N screen-based perimeter 236, 243
N pattern 69 set-up 28
nasal step 60-61, 143-144, 258, 260, 266-267 perimeter set-up
nerve iber bundle defect 68 eye patch 31
neurological disease patient 31-34
caecocentral defect 68 pupil 33
central defect 68 trial lens 33-34
disk edema 67 perimetrist, see visual ield examiner
hemianopia 67-68, 206, 231, 278 Perimetry 7
heteronymous defect 67-68, 278-279 point-wise event analysis 250-251
homonymous defect 67-68, 272-273 point-wise trend analysis 187-188
idiopathic intercranial hypertension (IIH) 67 Polar Analysis 113-115, 155-158
nerve iber bundle defect 60-61, 68 Polar Trend Analysis (PTA) 166-167, 187-190
optic nerve head drusen 67 Post chiasmal defect, see homonymous defect
optic neuritis 67, 276-277 primary open-angle glaucoma 259, 262, 264-266,
optic neuropathy 67, 274-275 268, 270
quadrantanopia 67-68, 227-229, 272-273, 279 Probabilities 107-108, 145-148
stroke 67, 272-273 progression 165-190
test patterns 67-70 selection of visual ields 176-178
tumor 67, 231, 278-279 ptosis 43-44, 76-77, 177, 230
typical defects 67-68 pulsar perimetry 52-53, 196-197
normal strategy 83-84 pupil 33, 44
normal tension glaucoma 257-258, 261, 263, 267, 269
normal visual ield 8-10, 18-22, 145-148 Q
normative data base 18-20, 237-238 quadrantanopia 67-68, 227-229, 272-273, 279
normative values 18-20, 237-238 qualitative strategy 56-57, 81-82, 90-95
quantitative strategy 56-57, 81-90
O
optic neuritis 67, 276-277 R
optic neuropathy 67, 274-275 rate of progression 170, 174-176
reaction time compensation 226-227
P refractive error 28, 40-42, 135-136
paracentral defect 60-61, 258-259, 261, 269-270 Reliability Factor (RF) 124-125
partial arcuate defect 60-61, 262-263 reliability indices 123-125
patient data retinal disease
date of birth 28, 40, 135-136 age-related macular degeneration (AMD) 70-71,
refraction 28, 40-42, 135-136 280
288 Index

branch central retinal artery occlusion 281 low vision 53, 201-202
branch central retinal vein occlusion 283 pulsar 52-53, 196-197
diabetic retinopathy 70-71, 73 SAP (standard automated perimetry) 51-53,
drug-induced maculopathy 70-71 193-196
macular hole 282 SWAP (Short-Wavelength Automated Perimetry)
retinitis pigmentosa (RP) 70-71, 211 52-53, 200-201
test patterns 70-73 strategy 56-57, 81-82, 96
typical defects 70-71 1-level test (1 LT) 91-92
retinal nerve iber layer (RNFL) 60, 62, 155-156, 187 2-level test (2 LT) 94-95
retinitis pigmentosa (RP) 70-71, 211 dynamic 83, 85-86
RNFL, see retinal nerve iber layer low vision 83, 86-87
normal 83-84
S qualitative 56-57, 81-82, 90-95
SAP (Standard Automated Perimetry) 51-53, 193-196 quantitative 56-57, 81-90
scotoma 207-209, 221-223 screening-P95 92-93
screen-based perimeter 236, 243 Tendency-Oriented Perimetry (TOP) 83, 87-90
screening 62, 92-93, 244 stroke 67, 272-273
screening 28 pattern 66, 92-93 structure-function relationship 155-156, 187,
screening-P95 strategy 92-93 258-271
semi-automated kinetic perimetry 231-232 subjectivity 20-21, 25, 243
sensitivity loss 18-19, 100, 103-106 suprathreshold test, see qualitative strategy
sensitivity threshold 12-17, 100-102, 236-237 SWAP 52-53, 200-201
sensitivity to light 9, 11-14
sensitivity, see sensitivity threshold T
setting up perimeter 28 technician, see visual ield examiner
set-up errors 28, 40, 135-136 temporal wedge defect 60-61
Short-term Fluctuation (SF) 124-125, 140, 224-225 Tendency-Oriented Perimetry (TOP) 83, 87-90
Short-Wavelength Automated Perimetry, see SWAP test duration 140
52-53, 200-201 test parameters, see examination parameters
signiicance of change 171-174 test pattern 54-55, 59
SITA fast 244 07 70, 72-73
SITA standard 244 10-2 72, 244
slope 170, 174-176 24-2 64, 244
sLV Trend Analysis 166-167, 180-182 32/30-2 64, 244
spot checking 207, 209 60-4 244
square root of Loss Variance (sLV) 119-120, 160-162 B (blind spot) 69
src 197 BG (blindness) 78
Standard Automated Perimetry, see SAP BT (Blepharoptosis) 76-77
static perimetry 12-14, 48-51, 205-206 D 73
stimulus exposure time 48 Esterman 74-75
stimulus luminance 14-15, 47-48, 217-218 F (fovea) 69
stimulus speed 218 G (glaucoma) 39, 62-63, 65
stimulus type 51-53 G-Peripheral 65-66
licker 52-53, 198-199 M (macula) 65, 71-72, 280, 282
function-speciic 52-53, 193-196 N 69
Goldmann sizes 52, 217
Index 289

three-zone strategy, see 2-level test visual ield

threshold test, see quantitative strategy abnormal 11, 19, 145-148
Threshold Values 245 age-dependency 18-19
threshold, see sensitivity threshold binocular 8-9, 74
Total Deviation 245-246 central 18, 60-64, 67
trend analysis 168-174 eccentricity 18-19
inluence of luctuation 172-173 interpretation 127-162
inluence of number of tests 173-174 monocular 8-9
linear regression analysis 172 normal 8-10, 18-22, 145-148
ordinary least square it 172 peripheral 18, 65, 67, 69, 72-73, 206, 211, 213
point-wise 187-188 progression 165-190
rate of progression 170, 174-176 spatial extent 8-9
selection of visual ields 176-178 spatial resolution 17-18, 54
signiicance of change 171-174 visual ield examiner 27
slope 170, 174-176 Visual Field Index (VFI) 247, 250
trend line 168-170 visual function 22
t-test 170-171 visual impairment 78
trial lens 29, 33-34, 41-42
trial lens calculator 41-42 W
trigger-happy 40, 138, 142-143 white-on-white perimetry, see SAP
t-test 170-171 widespread defect, see diffuse defect
tumor 67, 231, 278-279
two-zone strategy, see 1-level test

U
unreliable visual ields, see untrustworthy visual ield
untrustworthy visual ield 136-140
false negative answers 124-125, 138-139, 225,
248
false positive answers 45, 123, 125, 138-139,
177, 224-225, 247
fatigue 38
ixation loss 35, 39, 45, 248
incorrect patient age 40-41
lack of attention 40
learning 37-38, 243
lens rim artifact 43, 45
lid artifact 43-44, 77, 177
pupil size 44
refractive error 40-42
set-up errors 28, 40, 135-136
trigger-happy 40, 138, 142-143

V
Values 101-102
vector 207-209, 219-223
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 VISUAL FIELD INTERPRETATION EXAMPLES

NORMAL BORDERLINE EARLY TO MODERATE ADVANCED

Diffuse defect Local defect Local & diffuse defect

1 Correct patient & examination parameters? 1

2 Reliable, free of artifacts & trustworthy? 2
3 Diffuse loss? 3
1 Rank 59 1 Rank 59 1 Rank 59 1 Rank 59 1 Rank 59 1 Rank 59

-5 [#] -5 [#] -5 [#] -5 [#] -5 [#] -5 [#]

0 0 0 0 0 0
5% 5% 5% 5% 5%
DEFECT CURVE

DEFECT CURVE
5%
5 5 5 5 5 5
Defect (dB)

10 95% 10 10 95% 10 95% 10 95% 10 95%

95%

15 15 15 15 15 15

20 20 20 20 20 20

25 [dB] 25 [dB] 25 [dB] 25 [dB] 25 [dB] 25 [dB]

DD
DD

0.1 dB 1.3 dB 6.2 dB 1.3 dB 5.9 dB 19.3 dB

LD
LD

0.2 dB 0.2 dB 0.6 dB 7.0 dB 6.1 dB 4.7 dB

4 Significant local loss? 4

PROBABILITIES

PROBABILITIES
CORRECTED PROBABILITIES

CORRECTED PROBABILITIES
5 Assess shape & depth of defect. 5
GRAYSCALE (COMPARISONS)

GRAYSCALE (COMPARISONS)
CORRECTED GRAYSCALE (CO)

CORRECTED GRAYSCALE (CO)

+ + + + 9 9 8 + 19

+ + + + + + + 5 + + + + 5 8 11 10 5 5 8 5 6 6 8 + + 14 22

+ + + 8 8 10 17 10 17 17
+ + + + + + + 7 + 11 + + 15 13 10 + + 6 23 24
COMPARISONS

COMPARISONS

+ + + + + + + + + + + 6 7 7 6 26 21 19 23 + + 9 12 12 12 19 26 15 17 27
+ + + + + + + + + + + + + 5 7 7 + + 19 22 22 21 18 + + 14 13 24 25 21 24 9 18
+ + + + + + + + 5 7 7 + 21 15 13 17 10 10 11 12 14 8 9 17
+ + 7 12 5 9
+ + + + + + + + 9 6 6 7 + 5 6 + + + 5 + 17 22 11 15
+ + + + + + + + + + + + 8 6 6 6 6 5 + + + + + + 6 + + 7 5 + 19 10
+ + + + + + 5 9 5 + + + 5 5 5 12 19
+ + + + 7 + + + + + 22 27
+ + + + + + + + 9 15 5 5 + + + + 7 5 12 5 24
+ + + + 10 6 + + 7 7 22

+ + + + + + + + + + 6 + 7 8 8 6 5 5 + + + + + + 8 9 8 9 10 5 25

+ + + + 5 5 + + 12 + 20

+ + + + + + 7 + 13
CORRECTED COMPARISONS

CORRECTED COMPARISONS

+ + + + + + + + + + + + + + 5 + + + 6 + 5 + 7 + + 8 16

+ + + 7 + + 16 9 11 12
+ + + + + + + 5 + 5 + + 14 11 9 + + + 17 5
+ + + + + + + + + + + + + + + 25 20 18 21 + + + 7 6 6 + 6 + + 7
+ + + + + + + + + + + + + + + + + + 17 20 21 20 16 + + 8 7 18 19 15 5 + +
+ + + + + + + + + + + + 20 14 12 15 + + 5 6 + + + +
+ + + 10 + +
+ + + + + + + + + + + + + + 5 + + + + + + + + +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + + + + + + + + + + + + + + + + + + 8
+ + + + + + + +
+ + + + + + + + + 8 + + + + + + + + 6 + 5
+ + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 6

+ + + + + + + + 6 + +

6 For glaucoma: Significant cluster defects? 6

+ 2.5 6.0 17.4 17.1 26.1

CLUSTER ANALYSIS

CLUSTER ANALYSIS

+ + 8.5 6.6 19.2 23.7

+ + + 3.4 + 5.1 20.7 + + 17.0 22.5 20.6

+ + 6.1 15.5 11.1 10.1

+ + 6.6 3.0 3.2 17.0

+ + + + 7.2 6.1 + + 6.4 4.2 25.8 20.3

+ + 6.9 + 7.5 24.4

+ + 6.4 + 7.8 25.4
CORRECTED CLUSTER ANALYSIS

CORRECTED CLUSTER ANALYSIS

+
+ + +
+ 11.2 6.8
16.1 5.3
+
+ + 2.3
2.3 13.3 4.4

+
+ +
+ + 2.1 +
+ +
+ 19.4 +
+ +
+ 11.1 3.2 1.3
1.3
2.0
2.0 + +
+ 14.2 5.2 +

+
+ + +
+ 1.7
1.7 +
+ +
+
+ +
+ + + +
+ +
+ +
+ +
+ +
+ +
+ 6.5 1.0
1.0

+
+ + +
+ +
+ 1.6 5.1
+
+ + +
+ +
+ 1.9 6.1

7 For glaucoma: Where to look for structural defects. 7

POLAR ANALYSIS

POLAR ANALYSIS

S S S S S S
30 20 10 N T T N 10 20 30 30 20 10 N T T N 10 20 30 30 20 10 N T 30 20 10 N T
[dB] [dB] [dB] [dB] [dB] [dB]
I I I I I I

8 Severity? 8
MD
MD

-0.2 dB 1.0 dB 6.3 dB 6.5 dB 10.1 dB 21.7 dB

sLV
sLV

1.5 dB 1.9 dB 2.5 dB 8.3 dB 7.2 dB 5.6 dB

Excerpt from the Visual Field Digest | 8th edition | Haag-Streit AG | Köniz, Switzerland | HS Art. No. 1519.7020038.02080 | Copyright © 2019 HAAG-STREIT AG | ALL RIGHTS RESERVED