PERIMETRY

Introduction Guide

Perimetry Introduction Guide

Introduction into automated Perimetry using the OCULUS

Easyfield,
Centerfield 2 or
Twinfield 2

Published by:
F. Dorner-Schandl
Augenklinik Tbingen

Dr. med. B. Wabbels

Augenklinik Bonn

Prof. Gerald Kolling

Eike Barczynski

OCULUS Optikgerte GmbH

Muenchholzhaeuser Strasse 29
D-35582 Wetzlar / Dutenhofen
GERMANY
Phone: +49 (0) 641 20 05-0

FIRST EDITION

Perimetry Introduction Guide

Foreword
Thank you for the confidence which
you have placed in us by your interest
for or purchase of an OCULUS
perimeter.
OCULUS
is
an
ophthalmologic
company with a long and proud
tradition. For more than 110 years, it
has been our goal to produce modern,
innovative products which lighten your
workload in the routine of daily
practice.

We cooperate with many clinics and

practicing physicians and develop
performance specifications for new
instruments in close consultation with
them.
The introduction guide in front of you
will help to become familiar with the
new subject.
It cannot replace basic education in
visual field management but should be
useful to refresh knowledge.

OCULUS Optikgerte
Managing director and management team

OCULUS has been certified according to DIN EN

ISO 9001:2000 and 13485:2003 and therefore
sets high quality standards in the development,
production, quality assurance and servicing of its
entire product range.

Perimetry Introduction Guide

Content
Prefix........................................................................................................................................5
1 Introduction ...................................................................................................................5
1.1
Why using automated Perimetry? ..........................................................................5
1.2
Static or Kinetic Perimetry?....................................................................................5
1.3
The Oculus Perimeters ..........................................................................................6
2 History of Perimetry.......................................................................................................7
2.1
History of Perimetry in General ..............................................................................7
2.2
History of Oculus Perimetry ...................................................................................8
3 Technical Basics .........................................................................................................11
3.1
Luminance ...........................................................................................................11
3.2
The testing grid ....................................................................................................12
3.3
Examination Strategies ........................................................................................16
3.3.1
Threshold-oriented supra-threshold strategy ................................................16
3.3.1.1 Supra Threshold 2-zone............................................................................17
3.3.1.2 Supra-Threshold 3-zone ...........................................................................18
3.3.1.3 Supra Threshold Quantify Defects ............................................................19
3.3.1.4 Class Strategy...........................................................................................20
3.3.2
Threshold strategies .....................................................................................21
3.3.2.1 Full Threshold 4/2 .....................................................................................21
3.3.2.2 Fast Threshold ..........................................................................................22
3.3.2.3 CLIP Strategy............................................................................................24
3.3.3
Kinetic Perimetry...........................................................................................25
3.3.4
Color Perimetry.............................................................................................25
4 Practicing Perimetry ....................................................................................................26
4.1
Examination Advices for Exact Perimetry ............................................................26
4.1.1
General Information ......................................................................................26
4.1.2
General Advices ...........................................................................................26
4.1.3
Long distance correction during the perimetric examination. ........................28
4.2
Selection of Program ...........................................................................................29
4.3
Quality Control .....................................................................................................30
4.3.1
Fixation Control.............................................................................................31
4.3.2
False Positive ...............................................................................................31
4.3.3
False Negative..............................................................................................31
4.3.4
Short Term Fluctuation (SF) .........................................................................31
5 Basic Medical Information ...........................................................................................33
5.1
The Visual Quadrants ..........................................................................................33
5.2
Normal Eye ..........................................................................................................33
5.3
Defects depending on location of the defect in the optic pathway........................37
5.3.1
Prechiasmal defects .....................................................................................38
5.3.2
Defects due to damage to the optic nerve chiasm itself................................41
5.3.3
Defects due to damage posterior to the optic nerve chiasm .........................41
5.4
Defects depending on the location of defect within the visual field ......................42
5.4.1
Depression / Constriction..............................................................................43
5.4.2
Field Cuts / Sector Defects ...........................................................................43
5.4.3
Scotomas......................................................................................................45
6 Glaucoma....................................................................................................................47
6.1
Basic Medical Information on Glaucoma..............................................................47

Perimetry Introduction Guide

6.2
Glaucoma stages according to Aulhorn ...............................................................48
6.3
Examples of Glaucoma Printouts.........................................................................49
7 Further Examples........................................................................................................64
Suffix......................................................................................................................................66
Sources..................................................................................................................................67

Perimetry Introduction Guide

Illustration register
Figure 1: Tuebinger Hand Perimeter .......................................................................................8
Figure 2: Tuebinger Automatic Perimter ..................................................................................8
Figure 3: TAP...........................................................................................................................9
Figure 4: Twinfield .................................................................................................................10
Figure 5: Luminance Difference Sensitivity............................................................................11
Figure 6: Goldmann Test Points ............................................................................................12
Figure 7: Example for found scotomas ..................................................................................13
Figure 8: Easyfield Testing Points .........................................................................................14
Figure 9: Glaucoma Test from the Twinfield/ Centerfield .......................................................15
Figure 10: 2-Zone Test-strategy ............................................................................................17
Figure 11: 3-Zone Test-strategy ............................................................................................18
Figure 12: Supra Threshold Quantify Defects stratecy ..........................................................19
Figure 13: Threshold Bracketing Strategy..............................................................................22
Figure 14: Fast Threshold Strategie ......................................................................................23
Figure 15: CLIP Strategy .......................................................................................................24
Figure 16: Exampel picture for using correction lens .............................................................27
Figure 17: Example for Visual field reduction.........................................................................29
Figure 18: Visual Quadrants ..................................................................................................33
Figure 19: Example for an Easyfield measurement printout, healthy eye ..............................35
Figure 20: Example for an Easyfield measurement printout, reduced visual field..................36
Figure 21: Visual pathway......................................................................................................37
Figure 22: Altitudinal defects..................................................................................................38
Figure 23: Optic nerve atrophy ..............................................................................................39
Figure 24: "Curtain" defect.....................................................................................................39
Figure 25: Nerve fiber layers defects .....................................................................................40
Figure 26: Prechiasmal defect caused by swelling of the optic nerve....................................40
Figure 27: Chiasmal damage.................................................................................................41
Figure 28: Posterior damage to the optic nerve .....................................................................42
Figure 29: Left superior incongruous .....................................................................................42
Figure 30: Sector Defects ......................................................................................................43
Figure 31: Sector Defect measured with the OCULUS Easyfield ..........................................44
Figure 32: Relative Scotoma..................................................................................................45
Figure 33: Centro-Cecal scotoma ..........................................................................................45
Figure 34: Para-central scotoma............................................................................................46
Figure 35: Ring scotoma........................................................................................................46
Figure 36: "Seidels Scotoma" ...............................................................................................46
Figure 37: Glaucoma stage from:Rasterperimetrie mit dem Tbinger Automatik Perimeter48
Figure 38: Illustation fom Oyster, 1999 ..................................................................................49
Figure 39: Glaucoma stage 1.................................................................................................50
Figure 40: Enlarged blind spot ...............................................................................................51
Figure 41: Absolute scotoma caused by a glaucom ..............................................................52
Figure 42: 2 Zone supra threshold strategy ...........................................................................53
Figure 43: Glaucoma stage 2.................................................................................................54
Figure 44: 2 zone supra threshold strategy............................................................................55
Figure 45: Glaucoma stage 3.................................................................................................56
Figure 46: 2 Zone supra threshold strategy ...........................................................................57

Perimetry Introduction Guide

Figure 47: Glaucoma stage 3.................................................................................................58

Figure 48: 2 Zone supra threshold strategy ...........................................................................59
Figure 49: Glaucoma stage 4.................................................................................................60
Figure 50: Glaucoma stage 4.................................................................................................61
Figure 51: Glaucoma stage 5.................................................................................................62
Figure 52: Glaucoma stage 5.................................................................................................63
Figure 53: Enlarge blind spot .................................................................................................64
Figure 54: Hemianopsia.........................................................................................................65

Perimetry Introduction Guide

Prefix
This short guide does not intend to replace
any professional literature on perimetry. It
also cannot be a users manual for Oculus
perimeters. It is to be placed right in
between these two. It shall explain the
Oculus perimeters from a medical point of
view. Some parts may look like a guide in
perimetry in general. Some parts are
identical with the manual. Some parts are
completely different from both. However,

1
1.1

Introduction
Why using automated Perimetry?

Generally perimetric examinations have

three major aims. At first the perimetric
reading is helpful for the diagnosis in
general. At second they are used for
progress monitoring of diseases that affect
the visual field. At third they are used in
order to judge the visual performance for
example at drivers license tests.
When talking about the visual field of one
eye, on the first glance it might seem
interesting to define the absolute line of

1.2

being able to use a perimeter means to be

able to push the correct buttons at the one
hand but also means to understand the
result of the performed test also. This
scripture therefore should provide the link
between the manual and medical school. It
shall help you to use your perimeter in the
way you want to and to read the results
and get the information you need from the
examination.

vision around the eye. Taking a closer look

one will find out that the sensitivity of vision
within the complete field is of much more
importance. Numerous diseases start in
the central 30 degree radius around the
fovea. The automated perimeters allow to
define the sensitivity on each location up to
90 degree around the fovea, depending on
the individual product. Additionally the
examination is fast and easy to run and
can therefore be done by an assistant too.

Static or Kinetic Perimetry?

There are two general ways to perform

automated perimetry, static perimetry and
kinetic perimetry.
Static perimetry will give the patient a
stimulus (in most cases a white light spot)
for a short time at a certain position while
the patient is directed to look straight
ahead at a defined point of fixation. The
stimulus is presented in a given size and
brightness compared to the background
illumination and the patient will respond if

he saw it. By increasing or declining the

brightness of the stimulus, the instrument
will find out the threshold value as a ratio
between the stimulus brightness and
background brightness given in dB. As one
can see, the measured value is defined by
the lowest difference between stimulus and
background that the examined person
responds to at a certain location. By
measuring numerous spots throughout the
examined area, a map will develop

Perimetry Introduction Guide

representing the visual field of the tested

eye.
Kinetic perimetry does not measure the
complete area, but the outer line of vision
at a certain threshold value. Since the
vision decreases with rising distance from
the fovea, this method of examination
gives lines with a certain threshold value
around the fovea, so called isopters,
similar to height marks around a

1.3

mountainpeek on a map. The stimulus is

illuminated at a certain value outside of the
visual field and than slowly moved inwards.
The patient will respond as soon as he can
see it. After that the procedure starts
again, but from a different direction.
A regular visual field consists of 4 to 5
isopters and shows the blind spot. The
blind spot is found the easiest using a
small but bright stimulus, like I/4 according
to Goldmann.

The Oculus Perimeters

OCULUS
Optikgeraete
GmbH,
Dutenhofen, Germany produces three
different Perimeters: The Easyfield, the
Centerfield 2 and the Twinfield 2.
The Easyfield is the smallest unit of the
three. It offers static perimetry in a 30
degree radius. The test point is white on
white background and the test point
parameters are corresponding to the
Goldmann Standard.
The Centerfield 2 offers static perimetry up
to 36 degree and using fixation shift even
up to 70 degree. Furthermore it offers
kinetic perimetry and color perimetry,
meaning a blue stimulus is presented on a
yellow background. Additionally it offers

the clip strategy. The stimulus brightness

and size correspond to the Goldmann
Standard as well.
The Twinfield is the largest of the three
units. It offers static perimetry up to 90
degrees without fixation shift. It offers
kinetic perimetry and color perimetry,
presenting an either blue stimulus on
yellow background or red stimulus. Clip
strategy is included. Again, the stimulus
corresponds to the Goldmann Standard.
The projection system used in Centerfield
and Twinfield allows them, to display and
reproduce stimuli very exactly, while
offering programming features for kinetic
perimetry.

Perimetry Introduction Guide

History of Perimetry

Even though one might think that

Perimetry is a fairly new subject, it has a
rather long history that goes several
thousands of years back to the ancient

2.1

Greeks. Here we will try to give you a short

overview on the major historical steps and
the history of the development at
OCULUS.

History of Perimetry in General

Hippokrates (430-380 BC) was the first to

be known to get in contact with visual field
examination. He diagnosed a vague loss of
the visual field as an Hemianopia.
Leonardo da Vinci (1452-1519 AD)
discovered that the visual field temporally
reaches farer than 90 degrees from
fixation. From now on the development
kept on moving. In 1668 Mariotte found the
blind spot. In 1708 Boerhouve defined the
scotoma. The word traces back from the
greek word skotos, which means darkness.
A man called Young was the first to define
the outer boundaries of the visual field in
1801 and a man called Purkinje refined
Youngss work in 1825.
Only 31 years later Perimetry had its break
through. Von Graefe defined clinical
perimetry in 1856. He found sector /
curtain defects, enlarged blind spots and
central scotoma and classified them.

From now on the development did not stop

until today. Since the significance of the
visual field was now known, the
development of examination methods
started. Already one year later, in 1857
Aubert and Foerster developed the first
arch-perimeter.
In 1945 Goldmann developed the first bowl
perimeter and defined standards on the
stimulus. That was the final step into the
age of visual field examination as we know
it today.
Parallel, Harms developed perimetric
techniques, enforcing his work when he
came to Tuebingen, 1952, later supported
by Elfriede Aulhorn, while Louise Littig
Sloane was working on static perimetry in
the U.S.

2.2

Perimetry Introduction Guide

History of Oculus Perimetry

Oculus started to get involved with

perimetry
about
100
years
ago
manufacturing a Foerster-perimeter. In
1957 Oculus began to operate more
closely with the university eye clinic in
Tbingen. The goal was to develop an
instrument to examine the visual field. In
1959 the first perimeter was presented and
called
Tuebinger
Hand
Perimeter
(Picture1). This extremely complex system
was built more than 300 times and
distributed world wide until 1985. It was the
first perimeter that allowed static perimetry
and still serves as the underlying principal
of almost every automated perimeter on
the market today.
In 1976 the first Tuebinger Automatic
Perimeter was presented at the IPS
meeting in Tuebingen (Picture 2).

Figure 1: Tuebinger Hand Perimeter

Figure 2: Tuebinger Automatic Perimter

Perimetry Introduction Guide

Figure 3: TAP

It was followed by the TAP in 1980 at the

DOG in Kiel. This was the first OCULUS
perimeter that was computer controlled
and allowed an examination to run
automatically (picture 3). In 1995 Oculus
released the Twinfield, the first instrument
that allowed computer controlled static and
full kinetic perimetry.

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Perimetry Introduction Guide

Up to today, the Twinfield sets standards in

automated perimetry.

Figure 4: Twinfield

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Perimetry Introduction Guide

3 Technical Basics
In order to set up the testing conditions
needed and choose the right test for each
patient it is useful to understand some

3.1

basic technical principals of the used

perimeter.

Luminance

The luminance is a measurement to

describe the reception of brightness which
we experience when looking at an object,
for example the wall of a room. The
typically used measurements to quantify
luminance are candela/m (cd/m) and
Apostilb (asb), while 320 cd/m equals
1000 asb (cd/m x = asb). These two are
absolute values, meaning they are
comparable with a length in feet or yard,
but it is not common to use Apostilb
anymore. The relative decibel scale allows
to describe any physical value. It gives the
deviation to a reference value, which has
to be defined. +10 dB will describe a value
10 times as high as the reference value
and +20 dB will describe a value 100 times
as high as the reference value. The

Figure 5: Luminance Difference Sensitivity

stimulus of the Oculus Easyfield has a

reference value of 3180 cd/m above
background illumination, the Centerfield
and the Twinfield both have a reference
value of 318 cd/m above background
illumination. The background of the three
perimeters is homogenously illuminated at
10 cd/m. The result measured in each test
spot is the brightness difference between
the background and the dimmest stimulus
seen by the patient in negative decibel, the
so called Luminance Difference Sensitivity
(LDS). Therefore, if the patient does not
even see the brightest stimulus possible,
the value will be zero. The higher the value
is, the dimmer is the stimulus, the better is
the vision in this certain location. The
following figure will show this relation:

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Perimetry Introduction Guide

Please note, since these parameters are

different for every perimeter, especially for
perimeters from different manufacturers,
the results are not transferable from one to

another. If exams from different perimeters

are supposed to be compared, one has to
convert the decibel-values to cd/m-values
above background.

Depending on the perimeter different sizes

of stimuli can be used. In the following

figure you can see the luminance and the

size of the different Goldmann Test Points:

Figure 6: Goldmann Test Points

3.2
The testing grid
Usually it is not a problem to find large,
absolute defects, such as complete
quadrants or even half-eye defects. One
can even find them easily using fingerperimetry. It is much harder to find small
and tiny defects. The used grid plays an
important role in finding them. The used
grid acts like a fishing-net: the denser the
grid, the smaller can the defects be that

will be found. But also, the more spots

have to be tested and the longer it takes to
examine. This might be hard on the patient
and also the longer it takes the worse will
be the concentration of the patient.
Therefore the reliability of the examination
might decrease the longer the examination
takes.

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Perimetry Introduction Guide

Figure 7: Example for found scotomas

Picture 7 illustrates the relation between

the number of test locations and the found
scotomas.
Also, the position of the single spots has to
be considered. One important absolute
scotoma that has to be found by any grid is
the blind spot of the patient. The position of
the blind spot is of high importance, as a
reference for the doctor. Usually, it will be
found at 15 eccentricity, has a diameter of
5 to 6, 2/3 are below the horizontal
meridian and 1/3 is above the horizontal
meridian.

Additionally there are several defects

which respect the horizontal or vertical
meridian, meaning the 0 and 90 axis of
the visual field. The only way to find the
edges of these defects is by not placing
any test spots on both axis. If no spots are
on the axis the adjacent spots are close to
the axis on each side.
Also, on the retina several receptors will be
linked to one receptor group. These fields
of reception do become smaller towards
the centre of the visual field. Therefore the
density of the testing spots should be
higher in the centre than at the periphery.

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Perimetry Introduction Guide

The OCULUS Easyfield has the following grid of test spots:

Figure 8: Easyfield Testing Points

These test spots can be used in any

combination. To make the use of the
Easyfield more comfortable, it has
predefined areas. These areas are based
on the standard tests used in automated

perimetry and offer a good compromise

between density and testing time for nearly
any situation. If not, the perimetrist can
define her or his own program. The user
manual describes the areas and use.

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Perimetry Introduction Guide

The OCULUS Centerfield 2 and Twinfield 2

are built differently and can test any
wanted spot within their radius. Thus they
are not limited in the amount and locations

of test-spots and can even perform kinetic

perimetry. For glaucoma testing the
following grid is widely used:

Figure 9: Glaucoma Test from the Twinfield/ Centerfield

The Centerfield and Twinfield also use

predefined areas for their testing. But also,
they have the option of defining ones own

grid. Again, the manual will guide you

through details.

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3.3

Perimetry Introduction Guide

Examination Strategies

But not only the brightness and the testing

grid are important parameters to the
examination. Truly informative perimetric
findings are achieved only by presenting
test stimuli of different brightness in order
to derive conclusions about the threshold
of luminance difference sensitivity at each
grid location. This procedure is called the
"examination strategy".

3.3.1

All Oculus perimeters allow the free

combination of strategies with any
available grid and to store such
combination for repeated use. Moreover,
predefined combinations widely called
program
are
installed
to
make
standardized examinations easy, also for
the less trained operator.

Threshold-oriented supra-threshold strategy

The threshold-oriented supra-threshold

strategy deliberately foregoes exact
determination of the luminance difference
sensitivity at each location, but it traces it
quite closely. With this strategy the
presented stimuli are slightly brighter than

expected. The test point must be the

brighter the more peripheral the area being
examined is located, since luminance
difference sensitivity decreases towards
the periphery of the retina. This strategy
can be implemented in various ways.

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Perimetry Introduction Guide

3.3.1.1 Supra Threshold 2-zone

(available in Easyfield, Centerfield and Twinfield)
The threshold-oriented supra threshold
strategy deliberately avoids an exact
determination of the LDS threshold at each
point which is examined; rather, it localizes
defects by identifying deviations from the
normal course of the test during an initial
examination. This strategy thus makes it
possible to examine many locations in a
relatively short time and to reveal small
scotomas using a dense fishing-net.
A test stimulus of 6 dB brighter than
expected is presented (first presentation)
at each location which is being examined.

For example: a test point with 27dB is

presented if the expected sensitivity is
33dB.
The test point is classified as normal
(circle) if this test point is recognized by the
patient (i.e. the response button was
pressed).
If the patient does not react to the stimulus,
it is again presented with the same
brightness. If the patient recognizes it, this
location is classified as normal; if not, it is
classified as an absolute scotoma (black
square).

Start with expected brightness -6dB

Respond

Not respond

End
Dot OK

Retest
same brightness
Respond

End
Dot OK
Figure 10: 2-Zone Test-strategy

Not respond

End
abs. loss

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Perimetry Introduction Guide

3.3.1.2 Supra-Threshold 3-zone

(available in Easyfield, Centerfield and Twinfield)
The 3-zone strategy proceeds for the most
part in exactly the same way as the 2-zone
strategy. - However, if there is no response
to the second presentation, the stimulus is
again shown with full brightness (0 dB). If

the patient reacts to this test point, it is

classified as a relative scotoma (X),
otherwise as an absolute scotoma (black
square).

Start with expected brightness -6dB

Respond

Not respond

End
Dot OK

Retest
same brightness
Not respond

Respond

End
Dot OK

Retest
maximum brightness
Respond

End
rel. loss
Figure 11: 3-Zone Test-strategy

Not respond

End
abs. loss

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Perimetry Introduction Guide

3.3.1.3 Supra Threshold Quantify Defects

(available in Centerfield and Twinfield)
This strategy works like the 3-zone strategy. However, if the patient responds to
the stimulus when it is presented with
maximum brightness, the location is not

only classified as a relative scotoma but

the exact threshold value of the scotoma is
determined with the help of the 4/2 strategy.

Start with expected brightness -6dB

Respond

Not respond

End
Dot OK

Retest
same brightness
Not respond

Respond

End
Dot OK

Retest
maximum brightness
Respond

Test exact threshold

using the 4/2 strategy
Figure 12: Supra Threshold Quantify Defects stratecy

Not respond

End
abs. loss

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Perimetry Introduction Guide

3.3.1.4 Class Strategy

(available in Centerfield and Twinfield)
Since of course not every patient has the
same degree of sensitivity the Centerfield
2 perimeter is provided with six luminance
classes (luminance levels) at 5 dB
increments so that it can adapt to different
sensitivity levels. The luminance classes of
Central
threshold
luminance
measurement
TC

Central
Selected
threshold
luminance
luminance
class
measurement
at
the
15
meridian T15

the Centerfield have been selected

according to the average sensitivity level of
young persons. Each luminance class
corresponds to a collective body of
sensitivity values for the anticipated visual
field hill.

Symbol

1
30TC
22T15
25TC29 17T1521 2
20TC24 12T1516 3
15TC19
7T1511 4
10TC14
2T15 6 5
0TC 9
0T15 1 6
Chart 1: Relationship between threshold luminance in the center or on the 15 circle T15 and the
6 luminance classes

At the start of an examination you have

two options:
You can either directly select a luminance
class on the basis of pre-existing knowledge, as in the case of a follow-up examination, or you can determine the patient's
luminance class. There are two automatic
methods available for determining the luminance class, both of which essentially
consist in determining the threshold as
precisely as possible at suitable locations.
All the examiner must decide beforehand
is whether the macula is intact or whether
there may be a disease of the macula. If
the macula is intact, the central threshold
is determined directly. In this case the
computer automatically selects a luminance class that comes closest to the sensitivity level found by the threshold measurement.
If a defect is anticipated in the area of the
macula, then selection of a luminance
class should not be based on the central

threshold. Instead one should measure 4

threshold values at an eccentricity on the
45 and 135 meridians and use the best of
these values as a reference for
determining the luminance class.
Once the luminance class has been
defined a program determining LDS at
each grid point is executed automatically.
First of all the device presents a suprathreshold test stimulus whose luminance is
determined by the currently set luminance
class and the eccentricity of the point now
under study. If the patient recognizes the
point, then the examination at that point is
already finished. In this case one speaks of
the expected sensitivity or, if luminance
class 1 has been selected, of normal
sensitivity.
If the first stimulus is not recognized, the
perimeter tests for the presence of an
absolute defect by presenting a stimulus of
maximum luminance, i.e. 318 cd/m. If this

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Perimetry Introduction Guide

is not recognized either, the software

classifies an absolute defect at this
location.
If the patient sees this point of maximum
luminance, he may have a relative defect.
This is ascertained by presenting the point
3.3.2

with the same brightness as the first time.

If the patient fails to recognize the third
stimulus, the Centerfield 2 perimeter will
then in a fourth step determine the degree
of the detected defect and assign it to a
luminance class.

Threshold strategies

The threshold strategy determines the

threshold value as precisely as possible at
each grid location.
It must be remembered here that the
physiological LDS is not a mathematically
precise threshold but rather a transition
area
between
"recognition"
and
"nonrecognition" of a test stimulus. Within
this transition area the probability of
recognizing a test stimulus increases or
diminishes depending on whether it is
presented stronger or weaker. There is
thus no "precise" LDS threshold value;

rather, the threshold which is determined

with a perimeter must be regarded as
having a mall factor of uncertainty. This
amounts to 2-3 dB, depending on the
eccentricity of the measurement location. A
reliable statement about the LDS threshold
can be reached only through repeated
determination and subsequent appropriate
calculation of the mean value.
The threshold strategy almost always
requires far more presentations for exact
measurement of a test point. This should
be taken into account when selecting a test
grid.

3.3.2.1 Full Threshold 4/2

(available in Easyfield, Centerfield and Twinfield)
The "Threshold Bracketing Strategy", as it
is also called, determines the threshold
value as precisely as possible at each grid
location.
At the beginning of the examination, as in
the supra-strategy, the central threshold is
measured in order to arrive at an approximate estimate of the peak of the visual
field hill which is to be measured. This procedure yields quite serviceable starting
values for the examination.
The EASYFIELD Perimeter first extracts 4
points from the selected grid and examines
them in isolation, in order to present supra
threshold points as rapidly as possible. The patient would promptly tire if a large
number of points were to be presented below threshold. Looking at a smaller number
of points in isolation has proven to be in-

advisable: the examinee requires a certain

readapting interval in order to recognize a
point which has been presented first above
threshold and then dark again, since the
subsequent point is "blanked out" by the
previous, brighter point.
After completing its examination with these
points, the program automatically continues with the next four points.
If a point is regarded by itself, the strategy
is as follows:
The program first presents the point at the
expected sensitivity (corresponding to the
class).
Then the point is "narrowed down"
corresponding to the 4 dB / 2 dB strategy.
In this Centerfield and Twinfield strategy
differs in one aspect from the Easyfield. It
extracts five points from the selected grid

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Perimetry Introduction Guide

and examines them in isolation, rather than

only four.

Start with expected brightness

Respond

Not respond

Presentation 4
dB darker

Presentation 4
dB brighter

Respond

Not respond

Not respond

Respond

Presentation 2
dB brighter

Presentation 2
dB darker

Not respond

Respond
Respond

Not respond

End

Figure 13: Threshold Bracketing Strategy

3.3.2.2 Fast Threshold

(available in Easyfield, Centerfield and Twinfield)
This strategy, too, is used to determine the
threshold value at each grid location.
In contrast to the threshold strategy, four
points are not regarded here in isolation,
but rather the visual field is examined as a
whole.
The
problem
of
making
presentations "too long below threshold"
does not arise with this strategy, since the
threshold value which is sought is
determined by using a mean value derived
in each case from a presentation at

maximum and minimum brightness. - In

addition, this strategy uses the results of
points already examined in the immediate
vicinity of the points currently undergoing
examination. The Fast Threshold Strategy
is less informative than the Threshold
Strategy if the patient's answers are false,
but comes to the same results if his
cooperation
is
good,
while
being
considerably faster.

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Perimetry Introduction Guide

Search for neighboring points

Not found

Found

Starting value with

brightness extrapolated
from neighboring points

Starting value w ith

expected brightness

Presentation of points at initial brightness

Seen

Not seen

Upper bracketing limit = brightness

of the corresponding class + 10 dB
Lower bracketing limit = Current
brightness

Upper bracketing limit =

Current brightness
Lower bracketing limit = 0

Presentation of point w ith a

mean value derived from the
lower and upper bracketing
limits
Not seen

Seen

Upper bracketing limit =

current brightness

Lower bracketing limit =

current brightness

Discontinue if upper minus lower

bracketing limit is less than or equal to
2 dB

End

Figure 14: Fast Threshold Strategie

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Perimetry Introduction Guide

3.3.2.3 CLIP Strategy

(available in Centerfield and Twinfield)
Like the strategies "Threshold" and "Fast
Threshold", the CLIP strategy determines
the precise threshold value at every point
of the test grid.
However, the dot is not switched off unless
the patient is able to see it. The brightness
is continuously increased in steps.
Initially one dot per quadrant is pretested
to get better start values for the other dots

and to determine the patients reaction

time. The individual reaction time plays an
important role with this strategy. The faster
the patient's reaction time is, the faster the
brightness can be increased and the faster
the examination runs.
Measured values which are outside an
expected window are automatically
retested.

Measurement of central or peripheral threshold, determine reaction time

Pretest 2 dots per quadrant to adapt start values and to

correct the peripheral reaction time

Starting value with a class of corresponding brightness

The brightness is increased permanently corresponding

to the individual reaction time.

Seen or maximum brightness

Not seen

End of first part

Determine MS value per quadrant

Measured value is outside an
expected window

Retest dot
Figure 15: CLIP Strategy

Value OK

End

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Perimetry Introduction Guide

3.3.3 Kinetic Perimetry

(available in Centerfield and Twinfield)
Kinetic Perimetry is used primarily to
define the outer borders of the visual field.
But it can be used also, for measuring a
complete visual field or to map a scotoma.
The stimulus does change neither size nor
brightness. It will be illuminated beyond the
outer boundaries of the visual field and is
slowly moved towards the middle. As soon
as the patient sees he will respond. After
that, the procedure will be repeated, but
from different direction. That way a ring of
several positions where the patient will
start seeing a stimulus of a certain size
and brightness is produced. This ring is
called isoptere. After that the brightness
will be reduced and the procedure will be
repeated. That way one will receive
another isoptere, closer to the middle. The
completed picture will consist of four to five

isopteres, which define the visual field like

height marks define a mountain on a map.
Overall this method is a little easier on the
patient, and therefore it is advisable to use
it for patients who are overchallenged by
static strategies or are simply to old. This
method is especially useful to measure the
peripheral visual field.
If a scotoma shall be mapped exactly, this
may also be performed with kinetic
perimetry. The stimulus is switched on in
the middle of the scotoma and slowly
moved outwards. As soon as the stimulus
is moved out of the damaged area, the
patient will see it and reply. This way the
outer boundaries of a scotoma can be
found very easily. Please see the Twinfield
manual for more details.

3.3.4 Color Perimetry

(available in Centerfield and Twinfield)
Yellow-blue perimetry (SWAP = Short
Wavelength Automated Perimetry) is
particularly well-suited for detecting
juvenile maculopathy and glaucoma
patients under the age of ca. 40 years. The
problem of blue absorption by the lens

appears frequently in older patients; this

makes it difficult to distinguish in the
examination results between visual field
defects which result from retinal damage
and which result from blue absorption by
the lens (cataract!).

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Perimetry Introduction Guide

Practicing Perimetry

4.1
Examination Advices for Exact Perimetry
F. Dorner-Schandl, Univ. Augenklinik Tbingen
(In thankful memory of my teacher, Prof. Dr. Elfriede Aulhorn)

4.1.1

General Information

The usability and the meaning of a

perimetric reading is strongly reduced if
consistent examination conditions are not
met.
Methodical details may vary with the
different used instruments, but certain
basic rules have to be respected.
Important is also to have the same
conditions at follow up exams.

4.1.2

The following examination advices are

supposed to be clues for inexperienced
examiners. Experienced examiners will
due to their experience adjust the settings
and conditions to the individual visual field
and the cooperation of the patient by
themselves.

General Advices

In order to run the examination exactly,

one has to explain the examination to the
patient in simple words. To explain are for
instance the fixation control, reply control,
opportunities of taking a break and the
examination time. Patients have to be
motivated and not less important they have
to be calmed down if they are nervous and
answer all questions about the upcoming
examination. This will make the job much
easier and increase the cooperation
considerably.
The patient should sit as comfortable as
possible at the perimeter and the correct
head-position and fixation has to be kept.
Only correct fixation will lead to good
results.
The better eye is usually examined first.
This is important because that way the
patient can see the better and is more
relaxed when the worse eye is examined.

The eye that is not examined should be

covered by an Oculus Occluder. The
patient can open both eyes, that way both
eyes will have the same adaptation.
Some patients are confused by this, which
means, that the eye has to be covered with
a dark occluder. That might move the
threshold values a little.
Drops to widen the pupil, ointment or gel
should not be given before the visual field
examination.
Also of influence for the result is the width
of the pupil, it is therefore to be noted (the
smaller the width of the pupil, the less light
will enter the eye).
If less light hits the retina, we will receive a
reduction of the LDS or the isopteres will
be moved inwards a little, which shows
more in the middle than in the peripheral
field.

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Perimetry Introduction Guide

The same effect happens if the opacity of

the optical media is higher than normal.
Therefore it is important, to consider the
pupil widths and the opacity of the media.
Using the Twinfield, one has to make sure,
that no light from windows or strong lamps
shines into the bowl. Also one has to make
sure, that there are no shadows in the
bowl.

The eye should be moved to the middle of

the lens, which can be observed through
the monitor. The distance between the eye
and the correction lens should be one cm,
to avoid scotoma produces by the rim of
the lens. If the distance is less, the lens
might steam up, which produces relative
scotoma. If the distance is to large,
artefacts might occur, because the rim of
the lens blocks the view of the patient.

Figure 16: Exampel picture for using correction lens

The duration and the frequency of the

presentation of the stimulus has to be
adjusted to the patient. Especially at the
first examination, both eyes have to be
tested.
The correct lens, according to age and
accommodation has to be chosen, just as
the correct examination area and strategy.

The
examination
requires
high
concentration, therefore the surrounding
has to be calm.
If the results are not exceptable or no blind
spot has been found, the examination has
to be repeated completely or in the partial
area of interest.

28

4.1.3

Perimetry Introduction Guide

Long distance correction during the perimetric examination.

It is important, that the stimulus during the

visual field examination is displayed very
exact, otherwise too low LDS is simulated.
Therefore in a case of ametropia a
correction lens has to be used, which

complies to the examination standard of 30

cm.
An astigmatism of more than 1.0 dioptre
should be corrected also.

As standard value, the following is added to the far correction:

Age:

0-40 Years:
50-60 Years:
50-60 Years:
More than 60 Years:

about +0,5 D.
about +1,0 D.
about +2,0 D.
about +3,0 D.

Individual deviations are possible and have

to be considered in each single case. For
instance, latent hyperopia at patients
between 40 and 50 years need a higher
plus correction.
For instance:

Spherical and astigmatic lenses can be

converted, that way for the best optical
illustration the thinner lens can be used.

+4 sph = -3/90 into:

+1 sph = +3/0

(The cylindric lens is added to the sphere, the sign of the cylindric lens is switched and the
axis is turned 90.)
The correction should be used during the
examination of the areas of the visual field,
that show within the glasses, therefore up
to about 30 eccentricity. In the peripheral
field no correction is needed and only to be
kept if the fixation mark cannot be seen at
all. Otherwise, scotoma or a concentric
visual field reduction at the areas of the rim
of the glass can be simulated. Therefore
only thin rim corrections lenses are
-progression glasses
-multifocal glasses
-glasses with big rims
-toned glasses
-absorption edge glasses
-half glasses.

allowed, that
instrument.

fit

the

holder

of

the

The examination can aslo be done, with

the patients full glass near correction
glasses, contact lenses or, in the case of
good and sufficient accommodation, with
the own long distances glasses.
To avoid lens rim artifacts due to
inadequate correction the following must
not be used:

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Perimetry Introduction Guide

Figure 17: Example for Visual field reduction

Correction lenses of about -5 dioptre or

more, produce a smaller image on the
retina and an enlargement of the visual
field. The blind spot is a little larger and
moved outwards. On a kinetic examination,
the isopters are moved outwards also.

Positive correction lenses of about +5

dioptre reduce the visual field, the blind
spot is smaller and moved inwards. The
isopters of a kinetic examination are
moved inwards.

Literature: Rasterperimetrie mit dem Tbinger Automatik Perimeter (F. Dorner-Schandl, W.

Durst, G. Kolling, B. Leo-Kottler)

4.2

Selection of Program

We define Program as the combination

of a grid and of a strategy. In Oculusperimeters, several basic programs have
been installed to make it easy also for the
occasional perimetry-user to find a suitable
program for the most common pathologies.
Dedicated and experienced perimetrists
may want to alter parameters or to create
new programs for better adjustment to
individual patients needs or less common
patterns of scotomas.

There is a basic conflict of objectives in

perimetry: You want as much information
spatial and in the depth of the possible
scotoma. More information requires more
examination time, but, the longer this time,
the more mistakes will be made by the
patient
due
to
the
deteriorating
concentration.
Oculus has worked out grids which are
adapted to the physiology of the retina,
which helps optimizing the outcome within
a given examination time. Other grids are

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Perimetry Introduction Guide

made to facilitate comparisons with fields

generated at field analysers of other
manufacturers (the grids ending with -2).

So there are several questions to consider

for the selection or creation of programs:

Strategies are often proprietary of the

manufacturers, so it is hard to reach good
comparability here. Nevertheless, there are
two strategies, which are very common:

At first you should consider the general

constitution of the patient. The better, the
more extensive examinations you may
use.

1. Full Threshold this is recognized as

the
most
precise
strategy,
but
unfortunately, also the most time
consuming. It can be found in most visual
field analyzers and thus it is a good one if
compatibility with others is important.
Remember that the grid combined with this
strategy should not have more than
approx. 80 locations to test, to limit the
examination time to a reasonable level.

Do you want to compare with examinations

produced earlier (also at different
perimeters)?
Use
the
matching
parameters.

2. Suprathreshold (screening) there are

several variations in use (see chapter
strategies), so make sure that you use the
matching type.
Other strategies may be more appropriate
for the specific needs of an individual
patient. Generally, Fast threshold gives
reliable values, also CLIP has proved its
high reproducibility but needs patients with
a reasonable condition and reaction time.
In any case, remember that you should
stick with the once selected program in
order to allow comparison of the patients
performance over time.

4.3

For Glaucoma and macula suspicious

cases, use the programs proposed by the
software.
For neurological cases a screening
strategy with a simple rectangular (-2) grid
is sufficient.
Do you have a new patient with unclear
signs of visual disturbances? A screening
over the widest area available can give you
a first indication of the critical zone which
may then be examined with a threshold
strategy.
With longer experience, you may wish to
make more use of the facilities offered by
the open software structure; for the
beginning, it is recommended to use the
preset programs.

Quality Control

Visual field tests are used not only to

retrieve information for itself but also to
make decisions about treatment of the
patient. Therefore it is essential that we
have an idea about the reliability of the
results generated by the examination. The
clue for this reliability is apart from a
technically stable perimeter the patient.
Monitoring the patient should be done by

the operator, making the patient aware that

he/she is not alone, motivating the patient
and giving the chance for a break when it
becomes obvious that the patient is
stressed. Look for attempts to change
sitting or head position and for an
increasing frequency of blinking.

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Perimetry Introduction Guide

Apart from this human factor, which can

hardly be replaced by the machine, the
perimeters deliver quality control data,

4.3.1 Fixation Control

This is probably the most popular method,
available in Oculus-perimeters in two
different ways.

which are based on three main indices, in

most instrument types.
In the upper left part of the printouts the
quality
indices
can
be
found.

surrounding area. Already small deviations

of fixation loss will reliably be tracked as
the patient will not be able to see the rather
dim stimulus.

a) The central fixation control is useful in

patients with no macular diseases. It is
based on the principle of false negative.
Before the actual field examination, the
instrument determines the level of
sensitivity on the macula which has a
steep increase of sensitivity in a very small
area (approx. 2 degrees) compared to the
surrounding area. Within the examination
the central stimulus is randomly presented
at a brightness just a little higher than the
determined threshold but still darker than
necessary to be perceived by the

b) The Heijl-Krakau method is less

sensitive. It is based on the false positive
principle and uses the blind spot as area
where no response is expected. Compared
to the macula, the blind spot covers more
area and thus allows more deviation from
the gazing line before the index alerts the
operator. Especially in defects which
connect with the blind spot, this method is
questionable. However, it should be used
when the macula defects are affected.

4.3.2 False Positive

Falsely positive response to a stimulus that
under regular conditions cannot be seen
by the patient or that has not been offered

at all. Thus trigger-happy patients can be

found.

4.3.3 False Negative

Falsely negative response to a previously
recognized stimulus. Used in the Oculus

4.3.4 Short Term Fluctuation (SF)

At several (usually 10) spots the threshold
is determined a second time and
compared with the initially derived value.
This method used with threshold
strategies only - shows the crux of all the
software-based quality control methods:
The more presentations you make to get

central fixation control and not shown

separately.

clearer quality information the longer the

examination takes, BUT: With longer
examination, concentration and responsereliability of the patient deteriorate. In other
words: If you test SF you will find SF.

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Perimetry Introduction Guide

For this reason, modern, fast strategies

have reduced the extent of quality control,
stressing the importance of close
monitoring and motivating by the operator.

It is essential that any deviations from

normal fields have to be verified with at
least one more examination with at least
the same level of precision, before any
conclusions concerning possible diseases
or treatments are made!

33

5.1

Perimetry Introduction Guide

Basic Medical Information

The Visual Quadrants

Depending on the area of the visual field,

different terms are typically used to
describe the quadrants of each eye. As
one can see from the picture below, the
upper part of the visual field of each eye is

called superior and the lower part is called

inferior. The part next to the nose is
referred to as nasal while the outer parts
are called the temporal areas of the visual
field.

Figure 18: Visual Quadrants

5.2

Normal Eye

A normal and healthy eye produces a

printout as shown in the figure below. The
numbers on the top of the page provide
some basic information, such as the tested
area, the used strategy, the stimulus, the
background illumination and so on.
As you know each spot on the retina
provides perception for the corresponding
spot on the opposite side of the visual field.
Therefore a stimulus presented on the
temporal side of the eye is received by the
nasal side of the retina and a stimulus
presented on the superior side is received
by the inferior side. All printouts show the
visual field as the patient sees it. Therefore
the optic nerve head, which is nasal, is
represented by a blind spot in the temporal
side of the visual field.

The grids and maps below provide the

actual result of the test. The first grid
provides the threshold value in decibel of
each tested spot in the retina. The higher
the value is, the better is the patients vision
in this certain location. Thus a blind spot
produces the value 0. Looking at the
location of the optic nerve head, we
therefore find the value 0 in our grid. On
the right, the result is shown again, but as
a map rather than a grid. The lighter the
area is coloured, the better is the patients
vision. Visual field defects become obvious
very easily, e.g. one can immediately
identify the blind spot in this picture.
In the third grid one can see the deviation
from age related norm values. That means,
that the patient has an above average
perception of the stimulus if a positive
value is given and a below average
perception if a negative value is given. A

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Perimetry Introduction Guide

person who is perfectly within the average

would produce a 0 value in each location.
One that is above average would produce
a positive value in each location.
The fourth grid corrects the overall
deviation from the average. That way
general deviations (such as those
produced by a cataract) are disregarded. A
person who is above average in each
location and produced a + value in each
location will produce a grid of 0 values
again. A local deviation would show up
immediately because it produces strong
deviations.
At the right hand side of the corrected grid
are six single values. The value MS
refers to the mean sensitivity, the absolute
measured mean value. MD is the mean
deviation. This is the difference between
the mean sensitivity of the patient and the
age related norm value. RF is the
reliability factor of the examination. It is
produced by the fixation control and the
number of false positive replies. The
highest possible value is 1.0, but the value
should not be below 0.7. PSD is the

pattern standard deviation. It shows the

deviation of the pattern of the visual field
from the age related norm pattern. SF
shows the short term fluctuation, if it is
measured. CPSD is the standard
deviation for corrected patterns. In this
case the PSD-value is corrected by the
short term fluctuation.
The last two grids will display the
calculated
P-value.
It
shows
the
probability, that the measured threshold is
healthy. The second grid is again
corrected, to avoid the hiding effect of an
overall reduction. The second one of the
next two figures will show this very clearly,
since in a healthy eye no irregularities are
visible in this manner.
The defect curve gives an image of the
overall defect. All points are sorted by
value and not by position. Therefore the
highest value is entered first, than the
second-highest, than the third, and so on.
The results of the deviation map are
entered. Two (black) lines give the
standard range and the red line shows the
result of the actual patient.

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Perimetry Introduction Guide

Figure 19: Example for an Easyfield measurement printout, healthy eye

36

Perimetry Introduction Guide

Figure 20: Example for an Easyfield measurement printout, reduced visual field

37

5.3

Perimetry Introduction Guide

Defects depending on location of the defect in the optic pathway

In order to identify a defect on the grids

and maps it is important to have some
basic knowledge on the so called visual
pathway. Light that is transmitted through
the ocular media is first receipted on the
retina. As one can see from the below
figure an image on the right (1) is received
by the retina on the temporal side of the
fovea of the left eye (2) and respectively on
the nasal side of the fovea of the right eye

(3). It is transmitted by the optic nerve (4)

to the chiasm (5) and then on to the left
half of the brain (7). The optic nerve is
divided into three different parts: The area
before the chiasm (4), the chiasm itself (5)
and finally the area past the chiasm (6). In
the chiasm the nasal nerve fibres cross
and the temporal ones change their
direction towards the brain.

Figure 21: Visual pathway

The defects showing up on a visual field

test can be divided into three groups:
1. Prechiasmal defects: includes
any defect in the visual pathway
from the cornea to the chiasm.
2. Chiasmal
defects:
includes
defects in the chiasm itself.
3. Postchiasmal defects: includes
all defects between the chiasm
and the brain.
Depending on the location of the defect,
different maps are produced by a visual

field test. Therefore the characteristics of

the examination result gives hints to where
the problem is located. In the following
chapter the different characteristics of the
three different groups are described.
Please note, that the given descriptions
are not of any medical meaning. The
purpose is simply to point out the relation
between some possible defects and the
results given by the Oculus field analyzers.

38

5.3.1

Perimetry Introduction Guide

Prechiasmal defects

These are defects in the visual field

caused by a damage to the pathways that
are anterior to the optic chiasm, such as a
damage to the retina, the cornea or
choroids of the optic nerve head for
example. These defects are monocular in
nature, which means that they can show
up in one eye only. Please note, that since
a lot of diseases affect both eyes the same
defect might show up in both eyes.
Therefore, a binocular defect does not
necessarily mean that it is not prechiasmal,
but a monocular defect means, that it is
prechiasmal.
Also, altitudinal defects (defects that can
be identified as superior of inferior) that are
prechiasmal
generally
respect
the

Figure 22: Altitudinal defects

horizontal meridian. This means, that in

many cases the defect will not cross the
middle line between the upper and the
lower part of the visual field.
Due to their nature these defects can have
various shapes, locations and steepness.
The affected area is not necessarily
absolutely blind. It can simply have a
worse vision than expected. The following
pictures will give a short idea.
The first example would be macula
degeneration, a retinal damage. It will
produce a central scotoma like shown in
the next figure (right eye: no findings):

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Perimetry Introduction Guide

Another example of a disease anterior to

the optic chiasm is optic nerve atrophy in
one eye, which causes a central field

defect as well as in the left eye (right eye:

no finding) of the next figure:

Figure 23: Optic nerve atrophy

he third example to be mentioned can be

caused by retinal tears. It creates a so
called curtain defect, whereby this curtain
moves from the bottom to the top. The

Figure 24: "Curtain" defect

picture below shows a typical example. As

one can see, the defect shows up in right
eye only (left eye: no finding):

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Perimetry Introduction Guide

Also monocular in nature are nerve fiber

layers defects, caused by glaucoma for
instance, as in the left eye in the next

picture (right eye: no finding). Glaucoma

themselves are discussed separately in
chapter 6 of this brochure:

Figure 25: Nerve fiber layers defects

One other prechiasmal defect is caused by

swelling of the optic nerve head due to
papilledema or optic nerve head drusen.
The static perimetry shows an enlarged

blind spot in either one or both eyes. In the

figure below one can see the enlarged
blind spot in the right eye (left eye: no
finding):

Figure 26: Prechiasmal defect caused by swelling of the optic nerve

41

5.3.2

Perimetry Introduction Guide

Defects due to damage to the optic nerve chiasm itself

In the optic nerve chiasm the crossing

fibers are most vulnerable to damage. As
you can see from Figure 22 the nasal
fibers from each side cross at the chiasm.
Therefore the temporal side of the visual
field is most likely to be affected. One
common example of a problem causing
chiasmal damage is pituitary gland
enlargement.

The defect shown in the figure below is

called complete bitemporal hemianopsia. It
is called bitemporal because the temporal
side of both eyes is affected and
hemianopsia because the complete half of
the eye is affected.

Figure 27: Chiasmal damage

5.3.3

Defects due to damage posterior to the optic nerve chiasm

One typical sign of damages posterior to

the optic nerve chiasm is that the field
defect is homonymous. This means, that
the same side of each eye is affected. As
we know from Figure 22, the left part of the
visual field of both eyes is received of the
right half of the brain and the right part of
the visual field of both eyes is receipted of
the left half of the brain.

Due to the pathway of the optic nerve,

most post-chiasmal defects respect the
vertical meridian of both visual fields.
The picture below shows an example of a
so called right complete homonymous
hemianopsia. This defect is often caused
by a stroke. The stroke would be in the left
part of the brain since the defect is in the
right part of the visual field.

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Perimetry Introduction Guide

Figure 28: Posterior damage to the optic nerve

The third example of a post-chiasmal

defect is a left superior incongruous
homonymous quadrantanopia. It means,
that the left side of each field is affected,
superior refers to the upper half of each
field, incongruous because the defects are
not exactly the same in each eye,

homonymous because it affects both eyes

and quadrantanopia because it affects a
quadrant of each eye. As one can see from
this example, the fact that post-chiasmal
defects are homonymous does not mean,
that both defects have exactly the same
shape and size.

Figure 29: Left superior incongruous

5.4

Defects depending on the location of defect within the visual field

Visual field defects can not only be

described by the location of the cause of
the defect, but also by the location and
size of the visual field defect. Usually the

visual field defects can be divided into

three groups:
1. depression / constriction
2. field cuts / sector defects
3. scotomas

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5.4.1

Perimetry Introduction Guide

Depression / Constriction

A depression or constriction is a general

reduction of the overall sensitivity of the
visual field. The name depends on the
testing method. If the visual field was

5.4.2

tested with static perimetry it is called

depression. If it was tested with kinetic
perimetry it is called constriction.

Field Cuts / Sector Defects

Field Cuts or Sector Defects are defects,

that move the outer boundary of the visual
field inward. These defects can be caused
by retinal detachment for example.
Sometimes these defects are also called
curtain defect. The picture below shows
what such a defect can look like. The

Figure 30: Sector Defects

second picture shows an Easyfield printout

of such a field cut. The greyscale image
makes the curtain effect very obvious and
the defect curve shows a severe step,
typical for defects that make an area
completely blind.

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Perimetry Introduction Guide

Figure 31: Sector Defect measured with the OCULUS Easyfield

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5.4.3

Perimetry Introduction Guide

Scotomas

Scotomas are defects that show up within

the boundaries of the visual field. They can
have various shapes, positions, steepness
and relativity, depending on the cause of
the defect.
These defects can be described by the
terms shallow vs. steep and relative vs.
absolute. Additionally they can be
described in terms of defect depth.
An absolute scotoma is not sensitive to the
most bright stimuli available, thus this area
is absolutely unsensitive to these stimuli. A
relative scotoma is sensitive to brighter
stimuli, but not to relatively dim stimuli.

Relative scotomas can be deep or shallow.

A deep scotoma is an area in the visual
field that is not sensitive to any but the
brighter stimuli while a shallow scotoma is
sensitive to all stimuli except relatively dim
stimuli.
The defect depth refers to a value gained
from static perimetry. It is a more precise
quantitative value to describe the severity
of a scotoma.
Below you can see an example of a so
called central scotoma. It can be caused
by macular degeneration, where central
fixation is still possible.

Figure 32: Relative Scotoma

The figure 34 shows a common scotoma

called centro-cecal scotoma. It extends
from the blind spot toward the central
vision. This type of scotoma can be caused
by an optic nerve lesion.

Figure 33: Centro-Cecal scotoma

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Perimetry Introduction Guide

A so called para-central scotoma can be

seen in the next picture. It is located
around or near the central vision.

Figure 34: Para-central scotoma

A ring scotoma surrounding a normal fovea

is called peri-central scotoma. It can be
caused by plaquenil toxicity.

Figure 35: Ring scotoma

In the next picture the scotoma has the

shape and location of an enlarged blind
spot. It is sometimes also called Seidels
scotoma.

Figure 36: "Seidels Scotoma"

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Perimetry Introduction Guide

Glaucoma

Glaucoma are according to Douglas R.

Anderson the most common reason for
performing a visual field test in the usual
clinical practice. Even though the scotoma
caused by glaucoma are just the
6.1

symptoms of the actual disease, it is

inevitably of high importance to examine
the visual field. Therefore we will introduce
the basics of glaucoma as well as the
different stages on the printouts.

Basic Medical Information on Glaucoma

The term glaucoma describes several

diseases which end up in the same result if
not recognized in time: They destroy the
optical nerve anterior to the optic chiasm.
The most common glaucoma is the so
called open angle glaucoma. The majority
of all glaucoma patients suffers from this.
Slowly, without recognition by the patient,
the drainage canals of the chamber water
will be clogged. Therefore the water will
not drain as fast as it is produced and the
inner eye pressure will rise. Eventually the
eyeball will start to bend outwards
beginning at the weakest spot, the optic
nerve head. This will harm the optic nerve
fibres, the so called axons, and will
produce a decrease or loss of vision in the
areas served by the affected axons.
Eventually, if no treatment is performed,
more and more axons will be damaged
and can cause total blindness in the end.
Lost vision will not be retrieved through
treatment. But a medical treatment is
usually assigned to regulate the inner
pressure, in order to stop further damage
from occurring.
Another very common type of glaucoma is
the so called normal-tension glaucoma.
The optic nerve is harmed, even though
the intraocular pressure is not higher than
normal. However, the pressure seems to
be too high for this particular optic nerve.
Angle closure glaucoma, also called acute
glaucoma are much more rare than the two
above mentioned types. Here a sudden

cause clogs the drainage canals. The inner

eye pressure rises suddenly and causes
immediate symptoms, such as headache,
eye pain, nausea, rainbows around lights
at night and blurred vision.
The above mentioned types are so called
primary glaucoma, because the glaucoma
is not caused by any other harm or
disease. However, glaucoma can be
caused by several other problems.
Treatment of the source of the glaucoma
will usually stop it from expanding too.
The last kind to be mentioned is the
glaucoma from birth. In this case the
chamber angle has not developed wide
enough for the water to drain properly. It
needs immediate treatment, but since a
baby cannot perform a visual field test it
will not be discussed any further in this
introduction.
If a glaucoma is detected early enough, it
can be treated by medication or surgery.
As long as there is no severe loss of
vision, the eyes sight can be saved.
Unfortunately up to now, lost parts of the
patients vision can not be retrieved on
either way. Therefore it is of high
importance to check for glaucoma on a
regular basis. Since there is no or only
very small loss of vision in the early stage
of a glaucoma, follow up is a major part of
the saving of the patients eyes sight.
Also, the patient will probably not be aware
of the development until a very advanced

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Perimetry Introduction Guide

stage of glaucoma, because it is a

sneaking symptom. Thus, the visual field
test is a major factor in the glaucoma

6.2

prevention examination as well as in the

follow up.

Glaucoma stages according to Aulhorn

The development of the visual field defect

caused by glaucoma was examined and
classified by Prof. Dr. E. Aulhorn. Each
stage shows typical symptoms within the

visual field. Step by step they show the

increasing damage of the optic nerve
fibres.

Figure 37: Glaucoma stage from:Rasterperimetrie mit dem Tbinger Automatik Perimeter
F. Doner-Schandl, W. Durst, G. Kolling, B. Leo-Kottler, Tbingen, Germany, 1993

Stage 1: relative scotoma according to

the affected axons.
Stage 2: small absolute scotoma in the
Bjerrum region without
connection to the blind spot.
Stage 3: absolute scotoma in the Bjerrum
region with connection to the
blind spot, eventually including a
nasal step according to Rnne.
Stage 4: Further extension of the scotoma
into the visual field
Stage 5: Collapse of the complete visual
field. A small temporal island of
vision may remain.

Very typical for glaucoma is the so called

Bjerrum shape or Bjerrum region In the
picture below you see an image on how
the axons run on the retina. Please keep in
mind that you are looking at a two
dimensional picture and the actual eye is a
ball shape. However, the maps give an
idea why the scotoma often appears in an
arched shape, the Bjerrum shape.

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Perimetry Introduction Guide

Figure 38: Illustation fom Oyster, 1999

http://www.city.ac.uk/optometry/Biolabs/vispath1lab/Visual%20Pathways%20&%20Fields_inprogress.htm

6.3

Examples of Glaucoma Printouts

In the following examples printouts from

the different Oculus Perimeters will be
given and explained. They will show one
example for each stage of Glaucoma. They

are supposed to be a reference for the

doctor and also allow one to become
familiar with the printouts.

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Perimetry Introduction Guide

Figure 39: Glaucoma stage 1

This print shows a relative enlarged blind spot and an archuate relative scotoma inferior to
the fovea. Since none of the scotoma is absolute it is a glaucoma stage 1 acc. to Auhlhorn.

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Perimetry Introduction Guide

Figure 40: Enlarged blind spot

This visual field also shows an enlarged blind spot. There is a relative scotoma around the
blind spot. Another relative scotoma is on the right just below the horizontal meridian.

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Perimetry Introduction Guide

Figure 41: Absolute scotoma caused by a glaucom

There is an absolute scotoma right below the fovea and left of the vertical meridian. This one
was caused by a glaucoma also, but since the scotoma is already absolute, it is a glaucoma
stage 2 acc. to Auhlhorn.

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Perimetry Introduction Guide

Figure 42: 2 Zone supra threshold strategy

This shows the same examination as the Figure before, but this time a 2 zone supra
threshold strategy is used.

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Perimetry Introduction Guide

Figure 43: Glaucoma stage 2

This one shows the same situation as in Figure 42. There is an absolute scotoma right below
the fovea and left of the vertical meridian. This one was caused by a glaucoma also, but
since the scotoma is already absolute, it is a glaucoma stage 2 acc. to Auhlhorn.

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Perimetry Introduction Guide

Figure 44: 2 zone supra threshold strategy

This shows the same examination as the Figure before, but this time a 2 zone supra
threshold strategy is used.

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Perimetry Introduction Guide

Figure 45: Glaucoma stage 3

This one shows an archuate scotoma, that is absolute in some parts and connected to the
blind spot. Since it is caused by glaucoma, it is a glaucoma stage 3 acc. to Aulhorn.

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Perimetry Introduction Guide

Figure 46: 2 Zone supra threshold strategy

This shows the same examination as the Figure before, but this time a 2 zone supra
threshold strategy is used.

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Perimetry Introduction Guide

Figure 47: Glaucoma stage 3

Here one can see a glaucoma stage 3 acc to Aulhorn which already has a nasal Step acc.
Roenne. This step is a nasal sector defect, which includes the blind spot.

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Perimetry Introduction Guide

Figure 48: 2 Zone supra threshold strategy

This shows the same examination as the Figure before, but this time a 2 zone supra
threshold strategy is used.

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Perimetry Introduction Guide

Figure 49: Glaucoma stage 4

This defect is also caused by glaucoma. Since a larger portion of the visual field is covered
by an absolute scotoma, it is considered a glaucoma stage 4 acc. to Aulhorn.

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Perimetry Introduction Guide

Figure 50: Glaucoma stage 4

Shows also a glaucoma stage 4 acc. Aulhorn. The absolute defect is not as large as in
Figure 43, but it already covers a complete quadrant of the visual field.

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Perimetry Introduction Guide

Figure 51: Glaucoma stage 5

Here you can see an example of glaucoma stage 5 acc. to Aulhorn. The visual field has
collapsed completely. A small area of vision has remained in the middle. The threshold of 33
dB in the centre is still acceptable.

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Perimetry Introduction Guide

Figure 52: Glaucoma stage 5

Here is another example of glaucoma stage 5 acc. to Aulhorn. There is almost no more
vision left for this eye at all.

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Perimetry Introduction Guide

Further Examples

In the following chapter you will find further

examples of typical examination results.
The printouts will look differently, because
the examinations are made with different
strategies. Please keep in mind, that these

are just examples. In practice the printouts

may look different even with the same
diagnosis. Anyway they shall help you to
become familiar with the printouts.

Figure 53: Enlarge blind spot

Here you see a printout with an enlarged blind spot. It was examined with a supra threshold
strategy, therefore it does not give you any threshold values.

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Perimetry Introduction Guide

Figure 54: Hemianopsia

This picture shows a hemianopsia. It appears often due to neurological problems, e.g. a
stroke. Again, the examination was taken with a supra threshold strategy, therefore no
threshold values and no resulting maps and grids are displayed on this printout.

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Perimetry Introduction Guide

Suffix

We hope that reading this brochure gave

you more of an idea on perimetry in
general, how to use the Oculus perimeters
and how to understand the results.
However, it cannot be the only source of
information. We hope you now gained a
brief overview and we want to encourage
you to keep going in learning and using.
However, not even the greatest textbook or
the best school can provide every single

piece of information available. Even though

we as a manufacturer try to provide you
with every information you might need,
eventually you will lack a piece earlier or
later. In this situation we and our
distributors will be glad to answer your
phone-call or e-mail.
In this means we hope that you will
appreciate working with your instrument
and the multiple possibilities it offers you.

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Perimetry Introduction Guide

Sources

Rasterperimetrie mit dem Tbinger Automatikperimeter, Dorner-Schandl, A. et al.

Eigenverlag, Tbingen/Heidelberg 1993
Perimetrie, Lachenmayr, B., Vivell, P.M.O.: Thieme, Stuttgart 1992
Early visual field defects in glaucoma, Aulhorn E, Harms M., Leydhecker W (ed).
Glaucoma, Tutzing Symposium, pp 151-186, Basel, Karger. 1967
Automated Static Perimetry, Douglas R. Anderson, M.D., St. Louis, USA, 1992
Atlas der Computer Perimetrie, Jrg Weber, V. Verlag, Berlin, 1993
www.eyetec.net - Module 11 - The Visual Pathways and Visual Field Defects