ADVANCE REFRACTION AND VISUAL

SYSTEMS
Course Code- OD-133

Rabia Saeed
OD, [Link] Optometry
Lecturer, DOVS-FAHS
VISUAL FIELDS
Learning Objectives:

 What is Visual field?

 Extension of Visual Field
 Visual field testing
 Types of Perimetry
 Definition of visual field

• Visual field (VF) “that area of space that

a person can see at one time”
(Benjamin, 1998)
• Clinical testing of VF conducted
monocularly
• Monocular VF is 3-dimensional “Hill of
Vision”
Extent of visual field
 Perimetry

• Science of measuring VF =
PERIMETRY
• 2 testing strategies:
− Kinetic perimetry
− Static perimetry
 Kinetic perimetry
• Presentation of stimulus of known size and
intensity outside borders of VF or within
blindspot
• Move stimulus until detection
• Boundary when first seen ring-shaped locus
of points = isopter
• When size and intensity of stimulus is
changed
new boundary is mapped
• Useful to determine borders of larger or
deeper VF defects
 Static perimetry

• Presentation of stimulus in specific

location within VF
• Method better at detecting small scotomas
− e.g. early glaucomatous VF change
• Static perimetry can be performed in one
of 2 ways:
− Static supra-threshold perimetry
− Static threshold perimetry
 Terminology

• Units of measurement of a visual field

− degrees from fixation
• Scotoma
− area of reduced or absent visual sensitivity
inside an isopter surrounded by area of
normal or higher sensitivities.
 Types of scotomas

• Relative scotoma
− Area of depression in which target may
seem blurry
− Target of higher intensity and larger size
may be detected
• Absolute scotoma
− Area where retinal sensitivity cannot be
increased
− No increase in stimulus intensity is detected
Laterality of visual field defects

• Unilateral defect: affecting one eye or

field
• Bilateral defect: affecting both eyes or
fields
Visual pathway
 Confrontational visual fields

• Allows detection of moderate size VF

defects
Indications
• Screening test
• Useful in bedridden patients, children,
etc
Advantages and Disadvantages of
Confrontation VF test

Advantages Disadvantages

• Simple to perform • Detects gross defects

• Quick • Not used for

monitoring
• Does not
require special • Too much inter-
instrumentation examiner
variability
 Method 1

Several procedures:
• Facial Amsler (FA)
• Central Finger Counting (FC)
• Simultaneous Finger Counting
(SFC)
• Hand comparison (HC)
• Peripheral Finger Counting (PFC)
Preparation for Confrontation

• Overhead lamp directed

towards practitioner

• Practitioner and patient at

eye level and about 60cm
apart

• Px occludes LE and
fixates practitioner’s LE
with his RE
 Facial Amsler (FA)

• “Can you see my nose?

• “While looking at my nose, is there anything
missing or blurry or dimmer on my face?
• Can you see my eyes, ears, chin, top of my
head and eyebrows?”
• Detects
− central scotomas
− scotomas in the central field
 Central Finger Counting (FC)
• Fingers presented to Px in each of 4
quadrants separately
• “How many fingers do you see?”
• Start with a close fist
• Detects:
− absolute scotomas
Simultaneous Finger Counting (SFC)

• Two targets presented

simultaneously
− first in 2 upper quadrants
• − Second in 2 lower quadrants
• How many fingers in total do you
see?” Detects
extinction
phenomenon
 parietal lobe lesions
Simultaneous hand comparison
(SHC)
• Practitioner presents hands with palms
facing himself, side by side
• “As you look at my nose, is one hand
clearer or brighter than the other or
are they about equal?”
• Detects
− relative hemianopsia
 Simultaneous hand comparison

• Hands one above the other

− Nasally, then temporally
• “As you look at my nose, is
one hand clearer or brighter
than the other or are they
about equal?”
• Detects
− relative quadranopsias
− altitudinal
hemianopias
− nasal steps
Peripheral finger counting (PFC)

• Finger counting in periphery of

each of 4 quadrants
• Fingers presented just inside
boundary of examiner’s own field
• Allows comparison of examiner’s field
with Px’s field
• Alternative is kinetic confrontation VF
• Determines extremities of Px’s VF
 Recording the findings
For a normal visual field
• OD:
− full (with facial amsler testing method)
− comparable to examiner (with kinetic field
screening)
For a visual field with a restriction
• OD:
− restricted in superior temporal quadrant
Method 2: Kinetic confrontation VF
examination

• Determine boundaries of
VF
• Capable of detecting
defects within
boundaries
 Kinetic confrontation

• Move target from unseen to seen

• Examiner observes that Px does not lose
fixation
• Plot dimensions of blindspot
• Map VF of RE, repeat procedure for LE
 Tangent screen

• Kinetic investigation of VF
• More sensitive than confrontation or
finger counting fields
• Provides accurate charting of
central and paracentral VF defects
• Useful in testing patients with hysterical
fields
 Instrumentation

• Black felt background

− Semi-visible black stitching
• Circular every 5
• Radial stitching
• Tests central 30º of VF
• Testing distance - 1 meter
• Detects
− size and location of
larger scotomas
 Procedure

• Monocular
• Px directed to central fixation dot
• If Px cannot see central dot 2 lines of
white tape that cross at fixation dot are
applied
− Px fixate where he thinks 2 lines cross
• All plotting done from non-seeing to
seeing
• Determine threshold at 25°
temporally with 1mm white target
− Increase size of target incrementally
till Px sees target
 Amsler Grid

• Kit is a set of 7 charts

(10 X 10 cm)

• Used to detect small

abnormalities (~1) in
the central VF that
could remain
undetected by the
usual methods of VF
testing.
• Each chart has a different pattern and
recommended for different purposes
• Charts detect small central
scotomas or metamorphopsia
− Metamorphopsia visual perception in
which objects appear distorted.
 Chart #1
• Standard grid
• 20X20 white square grid
on a black background
• White central fixation dot
• Each square (5mm)
corresponds to 1 of VF at
the standard testing
distance of 30cm
• Chart reveals distortion,
relative and absolute
scotomas
 Chart #2
• Similar to first chart
• 2 diagonal lines intersect at
center of the grid
• Used for patient with a central
scotoma that cannot fixate the
central dot
• Lines orient the patient’s
fixation by allowing fixation
approximately where the lines
would cross
 Chart #3

• Similar to the first but

squares are red
• Useful for patients with
suspected central or
cecocentral scotomas that
are commonly due to
toxic (e.g. alcohol,
chloroquine, etc.) or
nutritional amblyopia
 Chart #4

• Composed of small white

dots (no lines) on a black
background
• Indicated for patients with
one or more paracentral
scotoma making it easier
to delineate the affected
areas
 Chart #5
• Chart consists of 20 white
horizontal lines evenly
spaced by 5mm on a black
background
• Chart may be rotated for
evaluation in any meridian to
facilitate the identification of
“oriented” metamorphopsia
which primarily affects lines
going in one direction
 Chart #6
• Similar to 5th chart except
its made of black lines on
a white background
 Also contains 2 additional lines in the
1 region above and below the
fixation dot
 Chart is meant to facilitate the
observation of metamorphopsia along
the reading level
 Chart #7

• Similar to chart # 1 but the

inner 6 X 8 which
corresponds anatomically to
the macular area includes
smaller 0.5 white squares
instead of 1
• Smaller grid is intended to
facilitate detection of subtle
visual disturbances in the
macular area
 Learning Outcomes:

Students will be able to understand

 Different testing procedure for visual field
References:

 Internet
 A.K Khurrana
 Optics and refraction- Elkington