COP16.

qxd:Layout 1 7/9/08 9:59 AM Page 1

August 31, 2008 Volume 7 • Number 16

Ophthalmology Contemporary

A Biweekly Publication for Continuing Medical Education in Ophthalmology

Glaucoma Visual Field Testing Update

Sarwat Salim, MD, FACS, and Peter A. Netland, MD, PhD

Learning Objectives: After reading this lesson, the participant should be able to:
1. Describe the differences between the Swedish interactive threshold algorithm (SITA) and full-threshold strategies.
2. List the criteria used with glaucoma progression analysis to determine progressive visual field loss in patients with
glaucoma.
3. Describe the underlying principles and clinical applications of short wavelength automated perimetry and frequency-
doubling technology perimetry.

Visual function assessment is an integral component of
glaucoma evaluation and management. Advances in com-
puter technology have allowed more sensitive and repro-
ducible visual field loss detection than was possible with
manual perimetry.1,2 In recent years, strategies have been
introduced to simplify the procedure for patients and to pro-
vide results in a more timely manner. In addition, emphasis
has been placed on the early detection of glaucomatous dam-
age and the ability to monitor progression in order to initiate
or modify therapy, as deemed necessary. This article discuss-
es new efficient threshold strategies such as the Swedish
interactive threshold algorithm (SITA) and new approaches
to identify progressive visual field loss in patients with estab-
lished glaucoma, including the glaucoma progression analy-
sis (GPA) software for the Humphrey Field Analyzer (HFA;
Carl Zeiss Meditec, Inc.). New perimetric tests also are dis-
cussed, including short-wavelength automated perimetry
(SWAP) and frequency-doubling technology (FDT) perime-
try, which are designed to detect early glaucomatous damage
before it manifests on conventional perimetry.
Many types of perimeters are used for visual field test-
ing, including HFA, Octopus (Haag-Streit USA), Dicon
Dr. Salim is Assistant Professor of Ophthalmology, and Dr. Netland is Siegal
Professor of Ophthalmology, Hamilton Eye Institute, University of Tennessee
Health Science Center, Department of Ophthalmology, 930 Madison Avenue,
Suite 470, Memphis, TN 38163; E-mail: ssalim@utmem.edu.
The authors have disclosed that they have no significant relationships with
or financial interests in any commercial organizations pertaining to this educa-
tional activity.
All faculty and staff in a position to control the content of this CME activi-
ty have disclosed that they have no financial relationships with, or financial
interests in, any commercial companies pertaining to this educational activity.
Lippincott CME Institute, Inc., has identified and resolved all faculty and
staff conflicts of interest regarding this educational activity.
The continuing education activity in Contemporary Ophthalmology is intended for ophthalmologists and other physicians
with an interest in the prevention, diagnosis, and treatment of ocular disorders.
1
LD 400 (Paradigm Medical Industries), Henson Pro (Tinsley
Medical Instruments), Oculus Centrefield (Oculus), Med-
mont, and Ophthimus (Hi-Tech Vision). This article concen-
trates on the HFA, one of the most commonly used perime-
ters in clinical practices.
Efficient Threshold Strategies
Currently, standard automated perimetry (SAP), or
white-on-white perimetry, is the most common form of
visual field testing performed in glaucoma practices.
With this procedure, achromatic stimuli of various inten-
sities are projected on a white background to determine
threshold sensitivity values.
Traditionally, a staircase or bracketing technique has been
employed to determine the retinal threshold measurement at
each test point on both Octopus perimeter and HFA. With
the full-threshold (FT) algorithm, a presumed suprathresh-
old stimulus is presented, and its value then is increased or
decreased by increments of 4 dB until the patient’s threshold
is crossed.3,4 The instrument then recrosses the threshold
with 2-dB steps to further refine the accuracy of the thresh-
old values. Although these double-reversal threshold meas-
urements are more accurate, they add significantly to the
total testing time, taking at least 15 minutes per eye to com-
plete the standard 30-2 program. In patients with glaucoma
with preexisting visual field loss, the test may be prolonged,
resulting in considerable fatigue and reduced reliability. In
addition, FT demonstrates significant variability with
increasing deficit depth, limiting the ability to determine
progression in these damaged areas.5
An alternative strategy, the FASTPAC threshold program
(Humphrey), was introduced. This program determines the
COP16.qxd:Layout 1 7/9/08
Contemporary Ophthalmology
EDITOR
C. Stephen Foster, M.D.,
FACS, FACR*
Clinical Professor of
Ophthalmology
Harvard Medical School
Boston, MA
Founder and President
Massachusetts Eye Research
and Surgery Institute
Cambridge, MA
Founder and CEO
Ocular Immunology and
Uveitis Foundation
Cambridge, MA
ASSOCIATE EDITOR
Kimberly C. Sippel, M.D.*
Weill Cornell Ophthalmology
Associates
New York, NY
ASSISTANT EDITOR
Fahd Anzaar, M.D.*
Research/Education Coordinator
Massachusetts Eye Research
and Surgery Institution
Cambridge, MA
EDITORIAL BOARD
Yonca Akova, M.D.
Ankara, Turkey
Esen Akpek, M.D.
Baltimore, MD
Richard L. Anderson, M.D.
Salt Lake City, UT
Sofia Androudi, M.D., Ph.D.
Thessaloniki, Greece
William Ayliffe, M.D.
London, England
Dimitri T. Azar, M.D.
Chicago, IL
Elizabeth Davis, M.D.
Bloomington, MN
Yosuf El-Shabrawi, M.D.
Graz, Austria
Arnd Heiligenhaus, M.D., Ph.D.
Munich, Germany
Neil R. Miller, M.D.
Baltimore, MD
Peter A. Netland, M.D., Ph.D.
Memphis, TN
Ron Neumann, M.D.
Ramat Hasharon, Israel
Carmen A. Puliafito, M.D.
Miami, FL
Carol L. Shields, M.D.
Philadelphia, PA
Jonathan Talamo, M.D.
Waltham, MA
Elias I. Traboulsi, M.D.
Cleveland, OH
Marco A. Zarbin, M.D., Ph.D.
Newark, NJ
9:59 AM Page 2
August 31, 2008
threshold with a single reversal using an itive responses are measured using “listen
increment of 3 dB. Although the FASTPAC time data,” in contrast to the use of tradi-
strategy cuts the total time in half compared tional catch trials. With this technique,
with FT, it has been reported to underesti- periods during the test when no positive
mate the severity of visual field defects.6 answers are expected are used to establish
In response to issues encountered with more accurate estimation of false-positive
FT and FASTPAC, SITA, for use on the responses. One such period is the time
HFA II 700 series, and tendency-oriented
interval after the stimulus onset to the min-
perimetry for use on Octopus 101 and 300
imum reaction time. Positive answers dur-
series, have been developed. Both of these
ing this period, which lasts for 180 to 200 ms,
efficient threshold strategies reduce the
are recorded as false-positive responses.
total testing time significantly compared The use of data from many of these peri-
with traditional strategies, without com- ods compared with a limited number of
promising the accuracy and reliability of catch trials improves overall accuracy with
the data.7,8 SITA has demonstrated similar reduction in total testing time.
test–retest variability compared with FT.5 The SITA is available as SITA Standard
It has been suggested that SITA may be (SS) and SITA Fast (SF), with mean test
more sensitive to early loss.4
times of 7 and 4 minutes per eye, respec-
SITA uses various approaches to obtain
tively. SS often is used to diagnose glauco-
threshold sensitivities in a more time-effi-
ma in patients in whom it is suspected and to
cient manner. Unlike the traditional stair-
monitor progression in patients with estab-
case techniques using discrete intervals,
lished glaucoma, whereas SF is reserved for
stimuli used in SITA represent threshold
estimates with a high likelihood of being screening purposes in patients likely to be
seen by age-matched normal individuals. normal. SITA can be performed for the cen-
Subsequent presentations of the target are tral 10-2, 24-2, and 30-2 programs (Figure
1) and the peripheral 60-4 test.
modified depending on the patient’s initial
The single-field analysis printout for
response.4,5 The test also is paced accord-
SITA is similar to the standard FT or FAST-
ing to the patient’s responses. SITA
repeats testing at a given point when the PAC layouts. The only exceptions are that
reliability indices are presented as percent-
difference from the initial presentation is
ages rather than fractions, and short-term
more than 12 dB, in contrast to the 4-dB
difference used with FT. In addition, SITA fluctuation and corrected pattern standard
does not involve double threshold deter- deviation values are not recorded. The
minations at 10 preselected points to grayscale appears slightly lighter than tradi-
determine short-term fluctuation. All data tional strategies, and this has been attrib-
analysis is performed with StatPac statis- uted to improved sensitivity detection from
tical software (StatPac, Inc.). reduced fatigue due to shorter test time.5,9
SITA employs a new method to estimate SF, although requiring shorter test time,
the frequency of false answers.8 False-pos- may underestimate scotomas. SS generally
Dr. Foster has disclosed that he is/was the recipient of grant/research support from Allergan, Cerimon, Eyegate, Ista, Merrimack, Novartis
and Sirion; is/was a consultant/advisor for Allergan, Bausch and Lomb, Eyegate, Merrimack, Novartis, Sirion, and Therakine; and is/was
a member of the speakers bureau for Alcon, Allergan, Bausch and Lomb, Inspire, Ista, Medpointe, and Merrimack. Dr. Sippel has dis-
closed that her spouse is/was a consultant to Alcon Laboratories, OptiMedica, Jerini Ophthalmic, and Neurotech. Dr. Anzaar has disclosed
that he has no significant relationship with or financial interest in any commercial organizations pertaining to this educational activity.
Contemporary Ophthalmology (ISSN 1537-5846) is published bi-weekly by Lippincott Williams & Wilkins, Inc., 16522 Hunters
Green Parkway, Hagerstown, MD 21740-2116. Customer Service Manager, Audrey Dyson: Phone (800) 787-8981 or call
(410) 528-8572. 24-Hour Fax (410) 528-4105 or E-mail audrey.dyson@wolterskluwer.com. Visit our website at LWW.com.
Publisher, Daniel E. Schwartz: Phone (410) 528-4020, Fax (410) 528-4105.
Copyright 2008 Lippincott Williams & Wilkins. All rights reserved. Priority Postage paid at Hagerstown, MD, and at additional
mailing offices. POSTMASTER: Send address changes to Contemporary Ophthalmology, Subscription Dept., Lippincott
Williams & Wilkins, P.O. Box 1600, 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116.
PAID SUBSCRIBERS: Current issue and archives are available FREE online at www.lwwnewsletters.com.
Subscription rates: Personal: $261.98 US and $328.98 Foreign. Institutional: $339.98 US and $373.98 Foreign. In-training: $111.98 res-
ident non-scored, US, $128.98 Foreign. GST Registration Number: 895524239. Send bulk pricing requests to Publisher. Single copies:
$13. COPYING: Contents of Contemporary Ophthalmology are protected by copyright. Reproduction, photocopying, and storage or
transmission by magnetic or electronic means are strictly prohibited. Violation of copyright will result in legal action, including civil and/or
criminal penalties. Permission to reproduce in any way must be secured in writing from: Permissions Dept., Lippincott Williams & Wilkins,
351 W. Camden Street, Baltimore, MD 21201; Fax (410) 528-8550; E-mail arnetta.queen@wolterskluwer.com. For commercial reprints,
contact Matt Westcoat at 410-528-4212 or matt.westcoat@wolterskluwer.com.
Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A mention of products or services does
not constitute endorsement. All comments are for general guidance only; professional counsel should be sought for specific situations.
2
COP16.qxd:Layout 1 7/9/08 9:59 AM Page 3
August 31, 2008
A
B
Figure 1. Swedish interactive threshold algorithm (SITA) Standard Tests 24-2 (A) and 30-2 GPA provides a simple plain lan-
(B) of the same eye show a nasal defect and an inferior arcuate defect. The defects are bet- guage message, the GPA alert, to
ter defined with SS 30-2.
is used, rather than SF, for long-term monitoring of patients
with glaucoma.
Glaucoma Progression Analysis
Detection of progressive visual field loss in patients
with glaucoma continues to be a challenge for clinicians.
Several methods have been used to judge progression,
including point-wise comparison, glaucoma change prob-
ability analysis (GCPA) for FT tests, various algorithms
used in multicenter clinical trials, and analysis of global
indices, such as mean deviation. 10
Nouri-Mahdavi et al. compared point-wise linear regres-
11
sion, GCPA, and the Advanced Glaucoma Intervention
Study (AGIS) method to predict visual field progression
using the longitudinal visual field data from AGIS. For both
point-wise linear regression and GCPA analyses, the criteri-
on for progression was defined as the presence of three or
more test locations that demonstrated worsening. These
points were not necessarily contiguous, and the changes were
confirmed on three consecutive visual fields. For the AGIS
criteria, progression was defined as an increment of four or
more points greater than the baseline value, with confirma-
tion requiring three subsequent field tests. The authors con-
cluded that all algorithms had low false-prediction rates and
that different methods might be more appropriate at different
stages of follow-up. For example, point-wise linear regres-
sion is sensitive to the number of points available for analy-
sis; therefore, it performs well once a number of visual fields
are available for interpretation. GCPA, on the other hand,
may predict outcomes better during early follow-up.
A new change analysis program, GPA, has been intro-
duced on the HFA 700 series.12 This software helps to
3
Contemporary Ophthalmology
detect glaucoma progression and is
designed for use with the SS and
SF examinations. GPA cannot be
performed for FASTPAC, central
10-2, or SITA-SWAP tests. GPA
highlights any change from base-
line that exceeds the expected clin-
ical variability. GPA analysis is
based on visual field information
obtained from multicenter clinical
trials involving patients with glau-
coma exhibiting the full spectrum
of the disease. Statistical methods
used for this analysis of progres-
sion also were developed in clini-
cal trials. Variations observed
between different tests were used
to define the limits of expected
variability. GPA also corrects for
media opacities, enhancing the
ability to focus on localized glau-
coma damage. Once consistent and
significant change is noticed, the
indicate progression.
For GPA, a baseline is estab-
lished with an average of two tests. Up to 14 follow-up
tests may be compared with the baseline. If the examiner
does not choose baseline fields, the GPA automatically
selects baseline tests, with preference for SITA tests. If
FT tests are used as baseline, follow-up tests must be
either SS or SF. Once a certain number of SITA tests are
available, a new baseline should be established with one
of the SITA versions and the previous baseline with FT
should be deleted. GPA verifies examination reliability
and excludes unreliable tests from analysis. GPA also
provides mean deviation graph and linear regression
analysis to help verify the similarity between two base-
line visual fields.
Three types of printouts are available with GPA, includ-
ing the single field analysis with GPA summary (Figure 2),
GPA baseline printout, and GPA follow-up printout. The
follow-up printout contains four columns of data for each
test, including the graytone, pattern deviation, deviation
from baseline, and progression analyses (Figure 3). The
deviation from the baseline plot compares the pattern
deviation of a test point to the average of the pattern of
deviation values from the baseline tests. The change at
each test point is recorded in dB notation. A zero value
means no change from the baseline, whereas a –4 value
indicates that the current tested point is 4 dB lower than
the pattern deviation for the same point in the baseline.
The progression analysis plot demonstrates statistical sig-
nificance of the decibel changes and uses a set of symbols to
identify a point that exceeds the expected variability. A single
white dot represents no change. An empty triangle indicates a
point that has changed compared against the previous base-
line test. A half-filled triangle indicates that change at that test
COP16.qxd:Layout 1 7/9/08 9:59 AM Page 4
Contemporary Ophthalmology
Figure 2. Single field analysis with glaucoma progression analysis (GPA). In this field, an
inferior arcuate defect is present with no progression noted.
point has been documented on two consecutive tests. A filled
triangle indicates presence of change at that test point on three the development of new perimetric tests, such as SWAP and
consecutive tests. All triangles identify points that have
changed by an amount that is significant at the p < 0.05 level.
X indicates a point that has data out of range for analysis.
When applicable, the GPA alert appears. When significant
change is seen in the same three or more points on two con-
secutive tests, the GPA interprets the pattern as “possible pro-
gression.” When significant degradation is seen in three or
more points on three consecutive tests, the GPA interprets the
pattern as “likely progression.” These three points do not have
to be clustered to document progression.
Although GPA simplifies and standardizes analysis for
change in glaucomatous visual fields, its significance
should be interpreted in the full context of a patient’s clini-
cal situation when determining the effectiveness of an
existing therapy or a need for more aggressive intervention.
Bengtsson et al. introduced a new perimetric index, the
13
glaucoma progression index (GPI), to calculate the rate of
glaucomatous progression. GPI is calculated based on sig-
nificantly depressed points in the pattern deviation probabil-
ity maps and is recorded in percentage after these values are
4
August 31, 2008
age-corrected, where 100% represents
a normal visual field and 0% repre-
sents perimetric blindness. The GPI is
plotted against the patient’s age, and
the linear regression analysis of GPI
over time can assist clinicians in mon-
itoring stability or progression of the
disease. The authors compared the per-
formance of GPI with the current stan-
dard index, the mean deviation index
(MDI), and they reported that glauco-
ma progression rates calculated using
the GPI were significantly less influ-
enced by cataract and cataract surgery
compared with rates based on MDI.
The GPI and its accompanying trend
analysis graph will be a new enhance-
ment on the GPA printout.
New Perimetric Technologies
Histologic studies have shown that a
significant number of ganglion cells,
up to 50%, may be lost before visual
deficits are manifested on SAP.14,15
Because of considerable redundancy
in neural pathways and the nonselec-
tive nature of conventional perimetry,
the visual deficits may not represent
the underlying neuronal damage truly.
There is some evidence that large
diameter ganglion cells may be prefer-
entially lost in early glaucoma.15,16 An
alternative hypothesis related to
redundancy in the visual pathways
suggests that by targeting a specific set
of ganglion cells with sparse distribu-
tion, the sensitivity to detect early
functional loss may improve.17–19 These theories have led to
FDT perimetry.
Retinal ganglion cells have been classified into several
types, including parvocellular, magnocellular, and konio-
cellular.20–22 The most abundant of these are the parvocel-
lular cells, constituting about 80% of total cell population.
The parvocellular pathway transmits information mostly
about color and form. The magnocellular and koniocellular
cells represent the remaining 20%. The magnocellular path-
way is responsible for transmitting information regarding
flicker or motion, whereas the koniocellular pathway is
involved with transmission of short or blue wavelength.
SWAP selectively measures the blue wavelength func-
tion by using a large size (V) blue stimulus (440 nm) on a
yellow background (100 cd/m2), taking advantage of the
known glaucoma-induced color vision deficit.23 The yel-
low background desensitizes the green and red cones,
sparing blue cones. The transmission of this short wave-
length is thought to be mediated by the koniocellular path-
ways. SWAP is available on HFA II series and Octopus 1-
2-3 perimeters. With the exceptions of a different color
COP16.qxd:Layout 1 7/9/08 9:59 AM Page 5

August 31, 2008 Contemporary Ophthalmology

deviation plot, which are not influ-

enced by generalized reduction and are
more sensitive indicators of localized
glaucomatous damage.
SITASWAP adds the efficient testing
methodology of SITA to the benefits of
SWAP testing, resulting in considerable
reduction of test time (3 to 6 minutes
per eye).30,31 It is available only on the
24-2 program. SITA SWAP has its own
normative data, and in a small number
of eyes tested, it revealed less inter-
subject variability and increased
dynamic range of the procedure.
However, these results have not yet
been validated in a larger sample.
FDT perimetry uses the frequency
double illusion, in which a sinu-
soidal grating of low spatial fre-
quency (<1 cycle/degree) is coun-
terphased with a high temporal fre-
quency (>15 Hz).32 The resultant
perceptual effect of doubling is
thought to be mediated by My gan-
glion cells of the magnocellular path-
way. These cells, representing only
2% to 4% of the total ganglion cell
population, characteristically have
large axon diameters with fast con-
duction velocities and are sensitive to
motion and contrast. Recently, there
have been suggestions that doubling
percept is not only a retinal phenome-
non, and that cortical mechanisms
may also play a role.33,34
FDT has shown high sensitivity
and specificity for the detection of
Figure 3. GPA baseline and follow-up printouts. Improvement in visual field defects is

glaucomatous visual field loss.35–38

documented with learning curve. The GPA follow-up printout shows an inferior arcuate
defect with no progression.

By selecting a specific subset of gan-

stimulus and the yellow background, SWAP is essentially glion cells with reduced redundancy, it can detect damage
a static threshold perimetry in which Goldmann stimuli earlier than SAP. FDT also seems to have less test–retest
are presented in the standard manner to determine thresh- variability compared with SAP, making it more appealing
old measurements with FT algorithm. Data analysis is to monitor progressive visual loss.37 Although used pre-
performed with STATPAC, and results are printed on the dominantly for glaucoma suspects and patients with glau-
standard single-field analysis layout. coma, it can detect retinal disease and some neuro-oph-
SWAP has been found to detect early glaucomatous thalmologic disorders.39
damage in patients with ocular hypertension, glaucoma Both threshold and suprathreshold (screening) tests can
suspects, and patients with glaucoma with early to mod- be performed with FDT.32 The two threshold layouts are
erate visual field loss.24,25 It may detect loss up to 5 years denoted C-20 and N-30. There are 16 square targets (four
earlier than SAP. SWAP also has been shown to identify per quadrant) along with a central circular target centered
abnormalities in diseases other than glaucoma.26–28 over the macula (Figure 5). The N-30 program incorpo-
Several concerns have been raised with SWAP testing. It rates two additional points in the nasal field. Therefore,
demonstrates higher test–retest variability than SAP and also there are 17 target locations tested in C-20 and 19 target
is more affected by media opacities, making the test less suit- locations tested in N-30. The contrast threshold is deter-
able in patients with coexisting cataract (Figure 4).29 The mined by presenting a stimulus randomly in any of the
duration of the test is relatively long compared with SITA, testing locations by means of a specialized bracketing
which may make it less efficient in clinical practice and can procedure known as modified binary search. The FT tests
be associated with patient fatigue and frustration. When inter- take about 4 to 5 minutes per eye. On the printout, the
preting results, it has been suggested that emphasis should be threshold values are given in dB followed by the total and
placed on the glaucoma hemifield test and pattern threshold pattern deviation probability plots. Reliability indices,
5
COP16.qxd:Layout 1 7/9/08 9:59 AM Page 6

Contemporary Ophthalmology August 31, 2008

measured with the use of catch tri-

als, are listed along with global
indices at the bottom of the printout.
FDT perimeter is useful for screen-
ing programs, given its qualities of
portability, low cost, tolerance to
refractive error, and short test dura-
tion.32,38 The two screening tests are
denoted C-20-1 and C-20-5. The C-
20-1 has a high specificity, being
suitable for examining large popula-
tion of patients to reduce the number
of people falsely classified as having
an abnormal visual field. The more
sensitive C-20-5 is used to detect
early signs of glaucoma in clinical
settings. The screening test takes
about 45 to 90 seconds per eye.
FDT perimetry can be performed
with a matrix of smaller points that
can be displayed in a format familiar
A B
to clinicians using the Humphrey
Matrix Perimeter. The current version
Figure 4. Short-wavelength automated perimetry (SWAP; A) and SS 30-2 (B) performed

of the Humphrey Matrix FDT pro-

on the same eye show diffuse reduction of sensitivity on SWAP secondary to the pres-

vides several enhancements over the

ence of concomitant cataract.

original model. It has built-in statisti-

cal analysis software and a hard drive
that allows data storage, thereby facil-
itating retrieval of fields for future
comparison. It uses smaller and an
increased number of targets, allowing
earlier detection and more accurate
progression of the visual field deficits.
With the newer target patterns, neuro-
logic deficits are also more precisely
defined. By use of the ZEST (zippy
estimation of sequential thresholds)
A
algorithm, which is similar to SITA
strategy of HFA, the total testing time
Figure 5. An inferior nasal defect

is reduced and is similar for patients

seen on the SITA Standard Test (A) is

with normal fields and those with

reproduced on FDT testing (B).

visual field defects. This feature con-

siderably reduces variability and
defines field defects more accurately.
The Humphrey Matrix offers five
threshold tests, including N-30-F,
24-2 FDT threshold, 30-2 FDT
threshold, the 10-2 FDT threshold,
and the Macula FDT. The N-30-F
uses the same number of test loca-
tions as the original N-30 program,
but it is more time efficient. The 24-
2 FDT and 30-2 FDT patterns test 55
and 69 points, respectively. The total
duration of the test is 5 minutes with
the 24-2 FDT and approximately 6 to
7 minutes with the 30-2 FDT.
Glaucoma hemifield analysis and
reliability indices are displayed, and
B
6
COP16.qxd:Layout 1 7/9/08 9:59 AM Page 7
August 31, 2008
a single or serial field overview can be printed with the
standard format of HFA printouts.
Conclusion
Automated perimetry has significantly contributed to
our understanding of visual function deficits in glaucoma
patients. Since its inception nearly three decades ago,
advances in computer technology with more complex
stimuli and efficient strategies have provided more accu-
rate and reproducible results as well as the flexibility to
compare these results over time. However, there is still a
tremendous challenge to find an ideal perimetric test that
is reliable, efficient, and truly reflects underlying neural
damage and progression. Although new technologies
seem promising, further refinement in clinical perimetry
is an important task and will continue to be an active
focus of research for the ophthalmic community.
REFERENCES
1. Katz J, Tielsch JM, Quigley HA, et al. Automated perimetry detects visu-
al field loss before manual Goldmann perimetry. Ophthalmology
1995;102:21.
2. Agarwal HC, Gulati V, Sihota R. Visual field assessment in glaucoma:
comparative evaluation of manual kinetic Goldmann perimetry and auto-
mated static perimetry. Indian J Ophthalmol 2000;48:301.
3. Anderson DR, Patella VN. Automated Static Perimetry, 2nd ed. St. Louis,
Mosby, 1999.
4. Allingham RR, ed. Shields Textbook of Glaucoma, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2005.
5. Wild JM, Pacey IE, Hancock SA, Cunliffe IA. Between-algorithm, between-
individual, differences in normal perimetric sensitivity: full threshold, FAST-
PAC, and SITA. Invest Ophthalmol Vis Sci 1999;40:1152-1161.
6. Spry PGD, Johnson CA. Advances in Automated Perimetry. Vol 20, Module 10,
in: Focal Points 2002: Clinical Modules for Ophthalmologists. San Francisco:
American Academy of Ophthalmology, 2002.
7. Bengtsson B, Heijl A. Evaluation of a new perimetric strategy, SITA, in
patients with manifest and suspect glaucoma. Acta Ophthalmol Scand
1998;76:368-375.
8. Olsson J, Bengtsson B, Heijl A, Rootzén H. An improved method to esti-
mate frequency of false positive answers in computerized perimetry. Acta
Ophthalmol Scand 1997;75:181-183.
9. Artes PH, Iwase A, Ohno Y, Kitazawa Y, Chauhan BC. Properties of peri-
metric threshold estimates from full threshold, SITA standard, and SITA
fast strategies. Invest Ophthalmol Vis Sci 2002;43:2654-2659.
10. Vesti E, Johnson CA, Chauhan BC. Comparison of different methods for
detecting glaucomatous visual field progression. Invest Ophthalmol Vis
Sci 2003;44:3873-3879.
11. Nouri-Mahdavi K, Hoffman D, Ralli M, Caprioli J. Comparison of meth-
ods to predict visual field progression in glaucoma. Arch Ophthalmol
2007;125:1176-1181.
12. Carl Zeiss Meditec Inc. Humphrey Field Analyzer II—I Series User’s
Guide. Dublin, CA: Carl Zeiss Meditec, 2003.
13. Bengtsson B, Heijl A. A visual field index for calculation of glaucoma rate
of progression. Am J Ophthalmol 2008;145:343-353.
14. Kerrigan-Baumrind LA, Quigley HA, Pease ME, Kerrigan DF, Mitchell RS.
Number of ganglion cells in glaucomatous eyes compared with threshold visu-
al field tests in the same persons. Invest Ophthalmol Vis Sci 2000;41:741-748.
15. Quigley HA, Dunkelberger GR, Green WR. Chronic human glaucoma
causing selectively greater loss of large optic nerve fibers. Ophthalmology
1988;95:357-363.
7
Contemporary Ophthalmology
16. Glovinsky Y, Quigley HA, Dunkelberger GR. Retinal ganglion cell loss is
size dependent in experimental glaucoma. Invest Ophthalmol Vis Sci
1991;32:484-491.
17. Johnson CA, Adams AJ, Casson EJ, Brandt JD. Progression of early glau-
comatous visual field loss for blue-on-yellow and standard white-on-
white automated perimetry. Arch Ophthalmol 1993;111:651-656.
18. Johnson CA, Adams AJ, Casson EJ, Brandt JD. Blue-on-yellow perimetry
can predict the development of glaucomatous visual field loss. Arch
Ophthalmol 1993;111:645-650.
19. Johnson CA, Samuels SJ. Screening for glaucomatous visual field loss
with frequency-doubling perimetry. Invest Ophthalmol Vis Sci 1997;
38:413-425.
20. Kaplan E, Benardete E. The dynamics of primate retinal ganglion cells.
Prog Brain Res 2001;134:17-34.
21. Curcio CA, Allen KA. Topography of ganglion cells in human retina. J
Comp Neurol 1990;300:5-25.
22. Johnson CA. Selective versus nonselective losses in glaucoma. J Glaucoma
1994;3:532-544.
23. Sample PA. Short-wavelength automated perimetry: its role in the clinic
and for understanding ganglion cell function. Prog Retin Eye Res
2000;19:369-383.
24. Johnson CA, Adams AJ, Casson EJ, Brandt JD. Progression of early glau-
comatous visual field loss for blue-on-yellow and standard white-on-
white automated perimetry. Arch Ophthalmol 1993;111:651-656.
25. Demirel S, Johnson CA. Incidence and prevalence of short wavelength
automated perimetry deficits in ocular hypertensive patients. Am J
Ophthalmol 2001;131:709-715.
26. Remky A, Lichtenberg K, Elsner AE, Arend O. Short wavelength automated
perimetry in age related maculopathy. Br J Ophthalmol 2001;85:1432-1436.
27. Keltner JL, Johnson CA. Short-wavelength automated perimetry in neuro-
ophthalmologic disorders. Arch Ophthalmol 1995;113:475-481.
28. Remky A, Arend O, Hendricks S. Short-wavelength automated perimetry
and capillary density in early diabetic maculopathy. Invest Ophthalmol Vis
Sci 2000;41:274-281.
29. Horn FK, Brenning A, Jünemann AG, Lausen B. Glaucoma detection with
frequency doubling perimetry and short-wavelength perimetry. J
Glaucoma 2007;16:363-371.
30. Bengtsson B. A new rapid algorithm for short-wavelength automated
perimetry. Invest Ophthalmol Vis Sci 2003;44:1388-1394.
31. Bengtsson B, Heijl A. Normal intersubject threshold variability and nor-
mal limits of the SITA SWAP and full threshold SWAP perimetric pro-
grams. Invest Ophthalmol Vis Sci 2003;44:5029-5034.
32. Anderson AJ, Johnson CA. Frequency-doubling technology perimetry.
Ophthalmol Clin N Am 2003;16:213-225.
33. Maddess T, Henry GH. Performance of nonlinear visual units in ocular
hypertension and glaucoma. Clin Vis Sci 1992;7371-7383.
34. White AJ, Sun H, Swanson WH, Lee BB. An examination of physiologi-
cal mechanisms underlying the frequency-doubling illusion. Invest
Ophthalmol Vis Sci 2002;43:3590-3599.
35. Ferreras A, Polo V, Larrosa JM. Can frequency-doubling technology and
short wavelength automated perimetries detect visual field defects before
standard automated perimetry in patients with preperimetric glaucoma? J
Glaucoma 2007;16:372-383.
36. Medeiros FA, Sample PA, Weinreb RN. Frequency doubling technology
perimetry abnormalities as predictors of glaucomatous visual field loss.
Am J Ophthalmol 2004;137:863-871.
37. Spry PGD, Johnson CA. Variability components of standard automated
perimetry and frequency doubling technology perimetry. Invest Ophthalmol
Vis Sci 2001;42:1404-1410.
38. Cioffi GA, Mansberger S, Spry P, Johnson C, Van Buskirk EM. Frequency
doubling perimetry and the detection of eye disease in the community.
Trans Am Ophthalmol Soc 2000;98:195-202.
39. Wall M, Neahring RK, Woodward KR. Sensitivity and specificity of fre-
quency of doubling perimetry in neuro-ophthalmic disorders: a compari-
son with conventional automated perimetry. Invest Ophthalmol Vis Sci
2002;43:1277-1283.
COP16.qxd:Layout 1 7/9/08 9:59 AM Page 8

Contemporary Ophthalmology August 31, 2008

CME QUIZ: VOLUME 7 NUMBER 16

To earn CME credit, you must read the CME article and complete the quiz on the enclosed answer form, answering at least seven of the 10 quiz
questions correctly. Select the best answer and use a blue or black pen to completely fill in the corresponding box on the enclosed answer
form. Please indicate any name and address changes directly on the answer form. If your name and address do not appear on the answer form,
please print that information in the blank space at the top left of the page. Make a photocopy of the completed answer form for your own files and mail
the original answer form in the enclosed postage-paid business reply envelope.Your answer form must be received by Lippincott CME Institute, Inc.,
by August 30, 2009. Only two entries will be considered for credit.We will provide your 2008 individual CME certificates on a quarterly basis (April,
July, October, and January) for those unexpired answer forms received by us during that quarter. For more information, call (800) 787-8981.
Online quiz instructions: To take the quiz online, go to http://cme.LWWnewsletters.com, and enter your username and password.
Your username will be the letters LWW (case sensitive) followed by the 12-digit account number on your mailing label. You may also
find your account number on the paper answer form mailed with your issue. Your password will be 1234; this password may not be
changed. Follow the instructions on the site. You may print your official certificate immediately. Please note: Lippincott CME Institute,
Inc., will not mail certificates to online participants.
Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to
provide continuing medical education for physicians.
Lippincott Continuing Medical Education Institute, Inc., designates this educational activity for a maximum of 1.5 AMA PRA Category 1
Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
To our Canadian subscribers: This activity may be claimed under Section 2 as defined by the Royal College of Physicians of Canada
for the Maintenance of Certification program. Approved by the Canadian Ophthalmological Society.

1. Which one of the following statements regarding threshold
strategies used in automated perimetry is true?
A. The full-threshold (FT) algorithm determines the thresh-
old by double reversal using 4-dB and 2-dB increments.
B. FASTPAC strategy determines threshold by single
reversal in 3-dB increments.
C. The Swedish interactive threshold algorithm (SITA) uses
the technique of visual field modeling to estimate thresh-
old values by extrapolating information from adjacent test
points.
D. All of the above
2. Which one of the following statements regarding SITA is false?
A. SITA compromises the accuracy and reliability of the visu-
al field defect by employing a “best guess” approach to
threshold estimation.
B. SITA strategies generally have higher values for differen-
tial light sensitivity compared with traditional algorithms.
C. SITA Standard takes only half as much time as FT
perimetry.
D. SITA Fast takes only half as much time as FASTPAC
perimetry.
3. Which one of the following statements regarding SITA strat-
egy is false?
A. SITA can be used for short-wavelength automated perime-
try (SWAP) testing.
B. SITA is available only for central 24-2 and 30-2 programs.
C. SITA does not calculate short-term fluctuation.
D. SITA is available only on HFA II.
4. Which one of the following statements regarding glaucoma
progression analysis (GPA) is false?
A. GPA simplifies analysis to document change in glauco-
matous visual fields.
B. GPA uses data of expected range of variability from
established patients with glaucoma.
C. GPA provides simple plain-language alert.
10. Which one of the following statements regarding FDT is true?
D. GPA does not correct for media opacities.
5. Which one of the following statements regarding GPA is true?
A. Only FTs can be used for baseline tests.
B. Only SITA versions can be used for follow-up tests.
C. GPA does not verify unreliable tests.
D. GPA can be used with the SITA-SWAP test.
6. Which one of the following statements regarding the inter-
pretation of GPA is false?
A. A small open triangle identifies a change that was not seen
on the previous follow-up test.
B. A filled triangle identifies change at p < 0.05 that is repeat-
ed in three consecutive tests
C. GPA alert appears when significant degradation is seen
in three or more points on two or three consecutive tests
D. Three points must be clustered to satisfy the criterion
for progression.
7. Which of the following statements regarding retinal ganglion
cells is false?
A. There is considerable redundancy in the visual system.
B. Magnocellular cells are involved in the doubling per-
cept of frequency doubling.
C. Parvocellular cells are sparsely distributed.
D. The koniocellular pathway transmits short wavelength.
8. Which of the following statements regarding SWAP is/are
true?
A. SWAP may detect visual field deficits up to 5 years earlier
than SAP by selectively targeting a subset of ganglion cells.
B. SWAP uses a yellow background to allow adaptation of
long and medium wavelength mechanisms.
C. SWAP is more affected by ocular media opacities than SAP.
D. All of the above
9. Which one of the following statements regarding frequency-
doubling technology (FDT) is false?
A. FDT is more affected by inherent and acquired color vision
deficits than SWAP.
B. FDT demonstrates less test–retest variability compared
with standard automated perimetry (SAP).
C. FDT is a faster procedure than SWAP.
D. FDT poorly defines hemianopic defects compared with
SAP.
A. Only screening tests can be performed.
B. Reliability indices are omitted given its short test duration.
C. FDT is more resilient to refractive error compared with SAP.
D. FDT utilizes the parvocellular pathway sensitive to color
and form.