De Castro, Noel Jr. G.

11447532 LBYMEMX 20 July 2017

Perimetry Test (Visual Field Testing)

1. What is it?
Our visual world is composed of images of colors, textures, edges and contrasts. In addition, these
images may be moving or flickering. The goal of visual testing is to quantitate of these functions.
Traditionally we have tested visual function as visual acuity - the capacity to discriminate the fine
details of objects and visual field - the portion of space in which objects are visible at the same
moment during steady fixation of gaze in one direction. Color vision testing, flicker sensitivity, contrast
sensitivity, pupillary responses and motion testing are some of the other methods of quantitating
vision.

Perimetry is the systematic measurement of visual field function. The two most commonly used types
of perimetry are Goldmann kinetic perimetry and threshold static automated perimetry. With
Goldmann or "kinetic" perimetry, a trained perimetrist moves the stimulus; stimulus brightness is held
constant. The limits of the visual field are mapped to lights of different sizes and brightness.
With threshold static automated perimetry, a computer program is selected. The most commonly
used one tests the central 30 of the visual field using a six degree spaced grid. This is accomplished
by keeping the size and location of a target constant and varying the brightness until the dimmest
target the patient can see at each of the test locations is found. These maps of visual sensitivity,
made by either of these methods, are very important in diagnosing diseases of the visual system.
Different patterns of visual loss are found with diseases of the eye, optic nerve central nervous
system.

Another definition:
Perimetry is a standard method used in ophthalmology and optometry to assess a patients visual
field. It provides a measure of the patients visual function throughout their ield of vision. The devices
used to perform this evaluation are called perimeters.
Perimetry is performed for several reasons: detection of pathologies, evaluation of disease status,
follow-up of pathologies over time to determine progression or disease stability; determination of
efficacy of treatment and visual ability testing.

2. Types of perimetry

1. Kinetic
Kinetic perimetry is a two-dimensional assessment of the boundary of the hill of vision. It involves the
presentation of a moving stimulus of known luminance or intensity from a non-seeing area to a seeing
area until it is perceived. The stimulus is moved at a steady speed along various meridia (clock hours)
and the point of perception is recorded on a chart. By joining these points along different meridians an
isopter is plotted for that stimulus intensity. Using stimuli of different intensities a contour map of the
visual field with several different isopters can be plotted. Kinetic perimetry can be performed by
simple confrontation or by means of a perimeter such as the Goldmann.

2. Static
A method of assessing fields in which the location of a stimulus remains fixed at a certain location
within the field, with the intensity increased until it is seen by the subject (or decreased until it is no
longer seen). In other words, the target intensity is increased (or decreased) until threshold is
reached. The most frequently used automated perimeter is the Humphrey Field Analyzer (HFA);
others include the Henson, Dicon and Octopus. Automated static perimetry now constitutes the
method used for the great majority of visual fields monitoring in the care of patients with glaucoma.

3. Suprathreshold
Suprathreshold perimetry involves testing with stimuli of luminance above the expected normal
threshold levels for an age-matched population to assess whether these are detected; in other words,
 testing to check that a subject can see stimuli that would be seen by a normal person of the same
age. It enables testing to be carried out rapidly to indicate whether function is grossly normal or not.
However, it is not highly quantitative, and so is usually reserved for screening.

4. Threshold
Threshold perimetry is used for detailed assessment of the hill of vision by plotting the threshold
luminance value in various locations in the visual field and comparing the results with age-matched
normal values. In Humphrey perimetry (see below), a stimulus of higher than expected intensity is
presented; if seen, the intensity is decreased in 4 dB steps until it is no longer seen (staircasing).
The stimulus is then increased again in 2 dB steps until seen once more. If the stimulus is not seen
initially, its intensity is increased in 4 dB steps until seen, then decreased in 2 dB steps until no longer
seen. Essentially, the threshold is crossed in one direction with large increments, then crossed again
to fine-tune the result with smaller increments. Threshold testing is quantitatively detailed and is
therefore used for monitoring glaucomatous fields.

3. Methods of stimulus presentation

Static perimetry (it is used for rapid screening and follow up of the diseases involving defects such as
scotomas, loss of peripheral vision and more subtile vision loss and is important in the screening,
diagnosing, and monitoring of various eye, retinal, optic nerve and brain disorders). Static perimetry
tests different locations throughout the field one at a time. First, a dim light is presented at a particular
location. If the patient does not see the light, it is made gradually brighter until it is seen. The
minimum brightness required for the detection of a light stimulus is called the "threshold" sensitivity
level of that location. This procedure is then repeated at several other locations, until the entire visual
field is tested.

Threshold static perimetry is generally done using automated equipment. It is used for rapid
screening and follow up of diseases involving deficits such as scotomas, loss of peripheral vision and
more subtle vision loss. Perimetry testing is important in the screening, diagnosing, and monitoring of
various eye, retinal, optic nerve and brain disorders.

Kinetic perimetry (is useful for mapping visual field sensitivity boundaries, and may be a good
alternative for patients that have difficulty with automated perimetry). Kinetic perimetry uses a mobile
stimulus moved by an examiner (perimetrist) such as in Goldmann kinetic perimetry. First, a single
test light of constant size and brightness is used. The test light is moved towards the center of vision
from the periphery until it is first detected by the patient. This repeated by approaching the center of
vision from different directions. Repeating this enough will establish a boundary of vision for that
target. The procedure is repeated using different test lights that are larger or brighter than the original
test light.

In this way, kinetic perimetry is useful for mapping visual field sensitivity boundaries. It may be a good
alternative for patients that have difficulty with automated perimetry, either due to difficulty
maintaining constant gaze, or due to cognitive impairment.

4. What is visual field testing used for?

Visual field testing is most frequently used to detect signs of glaucoma damage to the optic nerve. In
addition, visual field tests are useful for detection of central or peripheral retinal diseases of the retina,
eyelid conditions such as drooping (ptosis), optic nerve damage and disease, and conditions affecting
the visual pathways from the optic nerve to the area of the brain (occipital cortex) where this
information is processed into vision.

Screening for glaucoma: Peripheral vision loss is often an early and subtle sign of glaucoma. Visual
field tests are helpful in making the diagnosis of glaucoma, and repeat testing is used to monitor
treatment.
Screening and testing for lid droop (ptosis)
 Testing for toxicity from certain medications (for example, screening for toxicity from
hydroxychloroquine [Plaquenil], which can affect the central retina)
Measuring the extent of retinal diseases, such as retinitis pigmentosa
Detecting conditions affecting the optic nerve, such as tumors, injury, poor circulation or stroke, optic
neuropathy, swelling of the optic nerve (optic neuritis), compression from swelling in the eye socket or
orbit, and severe nutrient deficiencies
Detecting conditions that affect the visual pathways from the optic nerves to the occipital lobe of the
brain, including tumors, inflammatory disease, increased intracranial pressure, injury, poor circulation,
or stroke
Testing for malingering behavior or factitious
Visual inspection can be used for internal and external surface inspection of a variety of equipment
types, including storage tanks, pressure vessels, piping, and other equipment.

5. How is visual testing done?

Visual field tests are used to check for gaps in your range of vision. They can help detect eye
diseases or nervous system problems that limit your ability to see objects clearly in the entire visual
field or in one part of it. Several tests are commonly done to evaluate a person's visual field.
The confrontation test. Your doctor sits or stands 2 ft (0.6 m) to 3 ft (1 m) in front of you. You cover
one eye while fixing your gaze on his or her nose. He or she slowly moves a finger or hand from the
outer edge of your visual field toward the center and from the center toward the edge through all
areas of your visual field. You will focus your eye on your doctor's nose and signal when you first see
his or her finger or hand. The test is then repeated for the other eye.

The Amsler grid test checks for macular degeneration, a disease that causes loss of vision in the
center of your visual field. The test uses a 4 in. (10 cm)square chart camera.gif with straight lines that
form boxes. The grid has a black dot at the center. The chart is held about 14 in. (36 cm) from your
face. You cover one eye while focusing your other eye on the black dot. The test is then repeated on
the other eye. Tell your doctor if:
You cannot see the black dot.
You see a blank or dark spot (other than the center dot).
The lines in the grid look wavy, blurred, or curved instead of straight. You will be asked to point to the
specific abnormal area of the grid.

Perimetry testing uses a machine that flashes lights randomly at various points in the visual field. You
look inside a bowl-shaped instrument called a perimeter. While you stare at the center, lights will
flash, and you press a button each time you see a flash. A computer records the location of each
flash and whether you pressed the button when the light flashed in that location. At the end of the
test, a printout shows any areas of your visual field where you did not see the flashes of light. In an
alternative manual perimetry test, your doctor moves a light target and notes your visual field on
paper.

The tangent screen test uses a black screen with concentric circles and lines leading out from a
center point (like a bull's-eye). Sitting 3 ft (1 m) to 6 ft (2 m) away from the screen, you cover one eye
while fixing your gaze on a target point marked on the screen. Test objects of various sizes at the tip
of a wand are then moved inward from the outer edge of the screen toward the center. You will signal
when you can see the object, and that point is then marked on the screen. The points on the screen
where you see the objects are connected to provide an outline of your visual field. The test is then
repeated for the other eye. An alternative manual tangent screen test uses a white object against a
black background. If you wear glasses, you will keep them on for this test.

Color vision tests check your ability to distinguish colors. In the most commonly used color vision test,
you look for different colored numbers or symbols hidden in varying backgrounds of colored dots.
First, you are shown sample patterns and told what symbols and numbers you can expect to see.
You then sit at a table and cover one eye. The doctor holds the color test patterns about 14 in. (36
cm) away from you. Some patterns are harder to pick out than others. As the doctor holds up a
 pattern, you will identify the number or symbol you see and trace it using a pointer. Some patterns
may not have a number or symbol. The test is then repeated with the other eye.

6. What are the causes of visual field problems?

A common cause of loss of peripheral vision (also called a peripheral field defect) is optic nerve
damage from glaucoma. A simulation of peripheral vision loss is also known as tunnel vision.
Eye "strokes" (occlusions) that block normal blood flow to the eye's internal structures, including the
optic nerve, also can lead to loss of peripheral vision.

A stroke or injury also may damage portions of the brain where images are processed, leading to
blind spots in the visual field. Basic causes of peripheral vision loss include: glaucoma, retinitis
pigmentosa, eye strokes or occlusions, detached retina, brain damage from stroke, disease or injury,
neurological damage such as from optic neuritis, compressed optic nerve head (papilledema),
concussions (head injuries).

If you suspect you have lost peripheral vision, see your eye doctor for a comprehensive eye exam
that includes visual field testing. If you have a sudden decrease in peripheral vision, see your eye
doctor immediately. Sudden loss of peripheral vision may indicate a detached retina, which is a
medical emergency that must be treated as soon as possible to avoid permanent vision loss.
Vision changes and problems can be caused by many different conditions. Some include:
Presbyopia -- difficulty focusing on objects that are close. This problem often becomes noticeable in
your early to mid-40s.

Cataracts -- cloudiness over the eye lens, causing poor nighttime vision, halos around lights, and
sensitivity to glare. Cataracts are common in the elderly.
Glaucoma -- increased pressure in the eye, which is most often painless. Vision will be normal at first,
but over time you can develop poor night vision, blind spots, and loss of vision to either side.
Glaucoma can also happen suddenly, which is a medical emergency. Diabetic eye disease, macular
degeneration -- loss of central vision, blurred vision (especially while reading), distorted vision
(straight lines will appear to be wavy), and colors that look faded. The most common cause of
blindness in people over age 60. Eye infection, inflammation, or injury
Floaters -- tiny particles drifting inside the eye, which may be confused with retinal detachment. Night
blindness. Retinal detachment -- symptoms include floaters, sparks or flashes of light in your vision,
or a sensation of a shade or curtain hanging across part of your visual field. Optic neuritis --
inflammation of the optic nerve from infection or multiple sclerosis. You may have pain when you
move your eye or touch it through the eyelid. Stroke or TIA, brain tumor, bleeding into the eye,
temporal arteritis -- inflammation of an artery in the brain that supplies blood to the optic nerve and
migraine headaches -- spots of light, halos, or zigzag patterns that appear before the start of the
headache. Medications can also affect vision.

7. Instruments used for visual field testing

Visual field tests are used to check for gaps in your side (peripheral) vision. Your complete visual field
is the entire area seen when your gaze is fixed in one direction. The complete visual field is seen by
both eyes at the same time, and it includes the central and peripheral visual fields.
Infants and toddlers will not be able to read typical visual acuities charts, nor will students with
significant cognitive impairments. This can make the assessment more challenging and will also
make it difficult to get a precise acuity. For that reason, the doctor may use other tests or
measurement techniques in order to gather information about the child's vision.

Confrontation field test

A screening method for detecting gross visual field loss. An interesting visual target is slowly moved
inward toward the eyes of a child from various locations (above; below; from the sides) as the child
looks straight ahead. The examiner watches to see at what point the child notices the visual target
 coming from each direction and can determine if there seem to be areas of the child's visual field in
which the child cannot see.
Cover Test
Procedure for detecting eyes that are not in alignment, by watching for eye movements as a child's
eyes are covered and uncovered one at a time.
Photoscreening
A screening procedure in which a special camera takes photographs of the eyes. The resulting
pictures can identify eyes that may be nearsighted or farsighted or have astigmatism, eyes that are
not in alignment, and 'cloudiness' of the eyes that may indicate a vision problem.
Picture-based vision tests
Tests that use simple line drawing pictures, instead of letters or numbers, as targets to measure a
young child's visual acuity.
Preferential Looking Test
This is a visual acuity test for nonverbal children that use black and white striped patterns. As the
stripes get thinner (and thus more difficult to see), an evaluator observes to see if a child continues to
look toward the stripe patterns, an indication that the child can still see them. An acuity measure is
then calculated.

Resources:
http://webeye.ophth.uiowa.edu/ips/Perimetr.htm
https://www.haag-streit.com/fileadmin/Haag-
Streit_Diagnostics/perimetry/Visual_Field_Digest/Chapter_2/Visual-Field-Digest_chapter-2.pdf
https://sites.google.com/site/ophthalmology101/common-investigations/perimetry/02-types-of-perimetry
http://www.klinikamaja.rs/page/visual-field-test
http://www.medicinenet.com/visual_field_test/article.htm
http://tspndt.com/non-destructive-testing-industrial-supplies-blog/visual-testing-is-oldest-and-most-
common-ndt-technique
https://patient.info/doctor/visual-field-defects
http://www.teachingvisuallyimpaired.com/vision-tests--tools.html
Cunningham, Emmett T.; Paul Riordan-Eva (2011). "Chapter 2: Ophthalmologic Evaluation - Specialized
Ophthalmologic Examinations". Vaughan & Asbury's general ophthalmology. (18th ed.). New York:
McGraw-Hill Medical.
"Neuro-Ophthalmic Examination". Web MD, LLC. Medscape. Retrieved 29 November 2012