Tangent Screen Visual Field Testing

The tangent screen is a relatively simple and easy test to run and is much more sensitive than confrontation fields. The tangent screen has a black felt background with circular stitching every five degrees and will test out to thirty (30) degrees at one meter. It usually also has radial stitching that starts at the 180 meridian running through the fixation point every 22.5 degrees.

The tangent screen targets are pigments. Therefore, the test is more sensitive the dimmer the lighting is on the screen (more difficult to see). The light falling on the tangent screen should be 7 foot candles. This is not that important when using white targets as it is with colored targets. Therefore, if you do not have good control over the lighting in an examination room the test can be run with subdued lighting and not the recommended 7 foot candles. Colored targets the lighting is very important and one must try an have the illumination as to near to 7 foot candles as possible.

The nasal field represents the temporal retina and the temporal field represents the nasal retina. Tangent screen field testing is much more sensitive than either confrontation fields or finger counting fields. The later two are useful, but are best reserved for neurological field testing. Confrontation fields are most likely superior to finger counting fields, however, both may have merit if a advanced retinal detachment or neurological problem is suspected. There have been at least two cases, in the clinic, when these tests missed temporal lobe cysts. Neither will plot a field defect which is diagnostic of the causative problem or possible location. 1.) The smaller the target size the more sensitive the test. The more difficult the target is to see the more sensitive the test. The brighter the background illumination on pigmented targets the easier the targets are seen. Hence, there will be a reduction in the sensitivity of the test. This concept is just the opposite if the targets are illuminated targets (targets which are spots of light). 2.) The patient should be wearing their Rx. If they are presbyopic they should have a +1.00 D lens placed in a trial frame over their distant correction, assuming the tangent screen is at one meter. Patients should never wear glasses with multifocal lenses when being tested. 3.) If a patient has reduced central vision you should place a strip of masking tape from each corner forming an (X) through the fixation point. You would then ask the patient to look in the direction where they feel the two strips of tape would intersect. 4.) All plotting is done from non-seeing to seeing. It is a good idea to plot their blind spot first so the patient understands everyone has an area of non-seeing which is normal, plus, they will have a better understanding of what it is like when the target disappears. 5.) One must be careful when interpreting your findings. There are some conditions that may cause field defects that resemble glaucoma defects.(i.e., cataracts and drusens of the optic nerve heads) may result in an arcuate fiber scotomas. Only enlargement of the blind spot is not diagnostic of glaucoma. 6.) You should always plot from non-seeing to seeing from the periphery starting on only one side of the tangent screen. Plot on both the upper and lower part of the horizontal Raphe (looking for a difference of at least 5 degrees or more difference between the upper and lower nasal horizontal field; indicative of a nasal step and glaucoma). Plot one side of the vertical meridians (a difference could be indicative of a neurological problem: optic nerve and higher centers). You should never lean across to plot the opposite side, but rather walk around the back of the patient to the other side and repeat the same procedure. Make sure as you plot the hemi-field that you run the target through the blind spot to insure the patient is paying attention. You should also turn the target over so the patient can no longer see it, again checking to see if the patient is paying attention. About 90% of the time you should be watching the patient insuring they are indeed look at the fixation point and not your target. Color Fields Isopter Size White---Largest Isopter -- Tests Both Rods And Cones Yellow--- The Next Largest Blue--- Next Largest----Make Sure The Patient Can Tell You The Target's

Color! Red---Next Largest Isopter Green---The Smallest Isopter "Will You Buy Roy's Goods" acronym WYBRG With color targets patients will see the target before they can tell the color (rod function). 7.) You need to cover the whole field the central 25 to 30 degrees. Moving the wand (kinetic) in a serpentine motion covering the field on one side. The target should go through the blind spot, keep reminding the patient to look at the fixation point and report if the target ever disappears. It is important that the wand be moved slow enough so if there is a field defect it will be detected. 8.) When a field defect is found you must change the target size to determine if the scotoma is relative or absolute. An example scotoma would be the blind spot which is a negative scotoma and absolute scotoma. An absolute scotoma will have the same field defect size regardless of the target size. Relative scotomas have field defects that change in size as you change the target size and has sloping boarders that indicates a active or on going field defect. Recording of the of your testing is as follows: Test Target Size (mm) /over Testing Distance (mm) plus Target Color.

RELATIVE SCOTOMA

An absolute scotoma is a field defect that remains the same size regardless of target size. The field defect is absolute and corresponding retina has zero retinal sensitivity. A relative scotoma is a field defect that changes depending on target size. The field defect is relative and the corresponding retina has varying sensitivity. A relative scotoma is seen in an active and usually progressing defect.

Doubling the testing distance and doubling the target size will double the scotoma size

Remember, if you are using a one meter tangent screen and move it to two meters you will no longer be able to plot the blind spot or any other findings outside the central 15 degree field on a one meter screen. The Blind Spot Is Located @ 15 degrees on a 1 Meter Tangent Screen. It Will Fall Outside That Same 1 Meter Tangent Screen @ 2 Meters.

BLIND SPOT AND MONOCULAR FIELD

There are times when being able to move the tangent screen farther away will allow you to detect patients who are malingering. Our visual fields go out in a

constantly expanding funnel. Tubular fields, spiral fields, or hysterical fields are not related to any visual defects but rather psychological in nature or fatigue. If you can move the tangent screen closer or farther from the patient and you still get the same size field you know the patient is malingering or has somewhat of a psychological problem.

There are tangent screens and autoplots which use light as projected targets; in either case the effect on the sensitivity of the test is different from the tangent screen which uses pigmented targets. If you increase the amount of light falling on their surface, lighted targets, will reduce the patient's ability to see the projected target, hence, increasing the sensitivity of the test just the opposite of the tangent screen. If a instrument calls for one (1) foot candle of illumination and you use two (2) foot candles this will increase the sensitivity

of the test. Remember, if you are using color targets it is very important that one (1) foot candle of back ground illumination be used and the patient must tell you the color not just when they first see the target. It is very important you understand you should completely examine one side of the patient's field, then always walk behind the patient and repeat the same procedure for the opposite field. One further thing, if there is a black glove next to the tangent screen put it on before you start the test.

More About Scotomas A scotoma is an isolated area of depressed retinal sensitivity enclosed within the visual field. When no perception exists in the involved area the defect is absolute and has steep boarders. If an impairment of perception exists, it is a relative scotoma and has sloping boarders. Scotomas may also be classified as positive or negative according to whether the blind area is seen entopically by the patient as a black or gray shape, or is invisible to them and is detected only by special test. Opacities in the media always produce a positive scotoma, as do most circumscribed diseases of the retinal circulation or of the choriocapillaris that nourishes the rods and cones any lesion that tends to prevent the formation of an image on the (rods and cones) sentient layer. Any disease of the transmitting elements, tends to produce a negative scotoma glaucoma and retinitis pigmentosa are examples. By using targets of different sizes those parts of the retina just sensitive to a given threshold are determined; the lines joining these points of equal sensitivity are called isopters by Groenouw. An isopter represents connected points of equal retinal sensitivity for a given target size, testing distance, illumination level and target color. Therefore, test targets of varying size and color will give different isopter sizes. Some Scotoma Types

Central scotoma - includes the fixation point. Paracentral scotoma - lies adjacent to the fixation point with the greater part being on one side. Pericentral scotoma - surrounds the fixation point more or less symmetrically. Peripheral scotoma - lies outside the central area. Centro Cecal scotoma - includes the blind spot and the fixation point. Arcuate scotoma - usually includes the blind spot and arches into the nasal field. Zonular scotoma - may occupy any part of the field and the concavity is always directed to the fixation point. Bjerrum and Arcuate - are basically the same and usually relate to glaucoma type fields, extending from the blind spot to the horizontal Raphe. It is important to understand when speaking in terms of visual fields the nasal field represents the temporal retina and the temporal field represents the nasal retina. Scotoma Size Different size targets that give a different and proportional size scotoma. Different size targets that give proportionally the same size scotoma. Margins Lesion Scotoma Type

Sloping

Active

Relative

Steep

Inactive

Absolute

Contraction of "Field": You have an area where the size of the target or changes in its illumination makes no difference in the patients ability to see the target. It is an absolute blind area and always the same size regardless of target changes. Contraction of field is reserved to describe a collapsing of a part or the whole peripheral field. Depression: Will be blind to certain targets but will be sensitive and respond to changes in target size or changes in illumination. Depression of the field is also usually reserved to describe a collapsing of a part of the peripheral field.

Bilateral arcuate scotoma (inferior nerve fiber bundle defect) in chronic open angle glaucoma COAG. Binasal arcuate defects with nasal steps central

vision remained 20/20. Defects are dense and have steep margins, usually, these scotomas lack uniformity an have sloping margins.

(A): False baring of the blind spot results secondary to using too small a testing target not diagnostic of glaucoma. (B): True baring of the blind spot which is diagnostic of glaucoma and is a late stage finding.

The early basic damage in glaucoma is to the nerve fiber bundle and peripheral temporal retina. The above illustrated damage would correspond to visual field defects with a superior nasal step and superior temporal contraction. All visual field changes in glaucoma are variations of these fundamental defects. These losses would have to be diagnostic of an established glaucoma patient. The nerve fiber bundle always respects the Horizontal Raphe never crossing over. Higher levels, optic nerve and higher centers defects will cross over the Horizontal Raphe.

Tangent screen, visual field representation of the above never fiber bundle defect with a dense arcuate defect and nasal step. The contraction of the peripheral retina falls outside the limits of the tangent screens 30 degree field.
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