1. Power point copy of talk presented at 32 nd M.P. State
Ophthalmic Conference held from 17 th to 19 th October 2008 at
Ujjain
2. Kinetic Perimetry Dr Sanjay Shrivastava Professor of
Ophthalmology Regional Institute of Ophthalmology Gandhi Medical
College, Bhopal [email_address] www.eyeeducation.org
3. Visual Field
The Normal visual field is depicted as Traquairs Island of
vision surrounded by a sea of blindness
The three dimensional concept can be reduced to quantitative
values by plotting lines (isopters) at various levels around the
island or by measuring the height (sensitivity) at different points
within the island of vision.
4. Visual Field
The normal visual field and glaucomatous changes in visual
field are the same as when Bjerrum discovered the arcuate scotoma
using back of his consulting room door as a background for testing
visual field nearly 110 years ago.
Advances in the technology of visual field testing are changing
our perception of normal and abnormal visual fields.
5. Influence of Glaucoma on Visual Function
Understanding about natural history of progressive visual field
loss is continuously increasing with newer instruments and
technologies which has increased the sensitivity of test
The visual field defects that are caused by loss of retinal
nerve fiber bundles are the most common and familiar change, the
central vision is typically one of the last region to be lost
6. Influence of Glaucoma on Visual Function
Studies have shown that mild central and diffuse reduction in
the visual field can occur even in early stage of glaucoma
7. Visual Field defects in Glaucoma
Concentric contraction
Enlargement of blind spot
Angioscotoma
Nerve fiber bundle defects:
a. Scatter (fluctuation/localized minor disturbances): they are
variable threshold responses to repeated testing in the same area.
Scatter is studied with differential light threshold. It is
considered early warning sign of glaucoma
8. Visual Field defects in Glaucoma
b. Arcuate defect
c. Nasal step
d. Vertical step
e. Temporal sector defect
9. Other Conditions Affecting Visual Field
Neurological Disorders
Retinal Diseases including pigmentary dystrophies and vascular
diseases
10. Advanced Glaucomatous Field Defects
Complete double arcuate scotoma with extension to peripheral
limits in all areas except temporally
This results in a central island and a temporal island of
vision in advanced glaucoma
11. Other Measures of Visual Impairment in Glaucoma
12. Other Measures
Colour vision
Contrast sensitivity
i. Spatial contrast sensitivity decreases : impairment
correlates with the central field and optic nerve head damage
ii. Temporal contrast sensitivity (Flickering visual stimulus)
glaucoma patients have reduced function
13. Techniques of Visual Field Analysis
14. Perimetry
Determination of outer boundary of the visual field is one
aspect of testing the visual field, but it is of limited value.
More important is the fact that every point within the boundary has
certain characteristics of visual function.
Acuity away from the fovea can be measured for the purpose of
visual field testing. In perimetry functional ability in terms of
the weakest spot of light (visual stimulus) that can be seen at
different location in the visual field is quantified
15. Techniques of Field Charting
In visual field charting both the peripheral limits of a visual
field and the relative visual acuity of areas within those areas
are recorded
Visual fields can be charted by using kinetic and/or static
techniques with instruments that are operated either manually or
computer assisted (automatic)
16. Kinetic Perimetry
Involves moving of the test object from non-seeing to seeing
area and point at which it is first seen in relation to fixation
point. This procedure documents the boundaries of the visual field
for:
a. absolute limits
b. areas of relative differences in visual acuity with in the
field
17. Kinetic Perimeter
The best known of the kinetic perimeters is referred to as the
Goldmann-type projection perimeter. This type perimeter is named
after Dr. Hans Goldmann, a European ophthalmologist who did much of
the original design and testing on the hemispherical bowl
concept.
18. Kinetic Perimeter
Available Goldmann-type perimeters are manually operated. The
operator selects the target (stimulus), size and intensity, moves
the target within the bowl, monitors patient fixation and records
responses on the chart. In some cases, automatic recording is
provided which provides for automatic marking of the field of
vision chart each time the patient presses the response
button.
19. Kinetic Perimetry
Boundaries or contour lines are called isopters. The size of
isopter depends on the stimulus value of the test object
Kinetic targets: a stimulus velocity of 4 degree per second
appears to be optimal for all targets in the central and peripheral
visual field
Background illumination for manual perimetric techniques has
traditionally been mesopic to stimulate both rods and cones. Field
luminances used ranges from photopic to mesopic, 4 31.5
apostilbs
20. Static Techniques
Static technique involves the presentation of stationary test
objects using suprathreshold or threshold presentation
Suprathreshold static presentation is an off & on technique
in which an object just above the anticipated threshold for the
field is presented for 0.5 to 1 second and the point at which the
patient fails to recognize the target are noted. Spot checking is
done for areas of relative or absolute blindness usually in 30
degree central visual field
21. Static Techniques
Threshold static (Profile) perimetry measures the relative
intensity thresholds for the visual acuity of individual retinal
points within the field of vision. Light intensity is increased
gradually and the level at which patient is able to recognize
target is recorded or by decreasing light from suprathreshold value
to lowest stimulus value seen
Point can be tested in one meridian in radiating manner or
circular manner
22. Static Techniques
The more common technique with automated perimetry is to test
retinal points distributed in a portion of the visual field and
record the visual thresholds as symbols or numerical values
Threshold static perimetry has been shown to be more sensitive
than kinetic perimetry in detecting glaucomatous field loss
23. Manual Perimetry
Although automated perimeters are being used with increasing
frequency, the older manual perimeters still provide valuable
information, especially when the test is performed by a skilled
observer
24. Screening Techniques
Selective perimetry or the Armaly-Drance technique: in this
method Goldmann type perimeter with suprathreshold static perimetry
is used to test central area field and both suprathreshold static
and kinetic perimetry to examine the peripheral field with emphasis
on the nasal and temporal periphery
25. Automated Perimetry
The first era of perimetry mid 19 th century, the work of von
Graefe provided Tangent Screens and Arc perimeters.
They were lacking standardization
In middle 20 th century Goldmann perimeter brought
standardization
The problem of subjectivity of both patient and perimetrist
remained
26. Automated Perimetry
The problem of subjectivity of perimetrist was eliminated by
automation which began in the 1970s
Automated perimetry improved the uniformity and reproducibility
of visual fields
Utilization of computers has provided new capabilities that
were not possible with manual perimetry, including random
presentation of targets, estimation of patient reliability and
statistical evaluation of data at different levels
27. Automated Perimetry
Automated perimetry is more accurate and informative (but it is
neither fast nor cheap)
28. Factors Influencing Field
In perimetry the following factors influence the visibility of
white target:
1. Size/ diameter/ area of the spot
2. luminous intensity of the spot
3. Background illumination
29. Influence of moving spot
As the stimulus moves across the retina, a temporospatial
summation occurs that makes kinetic stimuli more visible than the
static ones. This phenomenon is more striking in disease conditions
in which large intense objects are not seen until they move
(Riddoch phenomenon). Statokinetic dissociation (Riddoch
phenomenon) seen in hemianoptic field defect
30. Neurological types of field defects
Prechiasmal defects
Chiasmal defects
Postchiasmal defects
31. Points in favour of Kinetic
Glaucoma rarely affects mean deviation appreciably without
first producing a localized defect
It is rare for a neurologic field defect to affect only the
area outside 30 degrees
32. Points in favour of kinetic
Automated static perimetry particularly, threshold perimetry is
different experience for patient from kinetic perimetry. Automated
static test is longer, and target is stationary and everything
appears dimmer to the patients. Therefore patient finds automated
perimetry more difficult and stressful compared to kinetic
perimetry
33. Kinetic Perimetry
In kinetic perimetry the test consists of sequence in which the
light comes on, gets brighter then he conveys its recognition by
pressing button, then light goes off, then again the stimulus comes
in similar manner.
Whereas in automated static perimetry the light goes on and
stays only for 0.2 second and it goes off irrespective of whether
patient see it or not and respond to it
34. Why is Goldmann Kinetic Perimetry so important
Kinetic perimetry is optimal for the more steeply descending
periphery and is much faster than the static method in this region.
It is ideal for advanced defects or patients having problems
understanding static testing. Static perimetry is ideal for
measuring the rather flat shape of the central 30 field and is more
sensitive than the kinetic method to detect early visual field
loss.
35. Kinetic Perimetry
Many patients hate perimetry, as it demanding task that
requires attentiveness and an effort to give the correct answer ,
the test is as stressful as school examination. The patient must
realize that the field examination is a subject medical test of
their visual function and it is not to test their intellectual,
artistic or physical abilities
36. Disadvantages of kinetic perimetry include:
the lack of automation provided by most instruments,
lack of computerized, normative, age-related comparison of
results,
the need for an experienced tester,
the potential for missing subtle scotomas,
and the length of time required to perform the tests
37. Shortcomings of traditional Goldmann kinetic perimetry
Regular training of examiner is reflected in the quality of the
result
Regular manual calibration of the instrument required
Quality guidelines recommended (Standard set of parameters,
Verification of the blind spot, Surveillance of the eye)
38. Automated Kinetic Perimeters
Tasks that can be performed with present generation of
automated perimeters
1. Evaluation of central and peripheral visual fields
2. Evaluation of blind spot
3. Correcting for reaction time
4. Examination of peripheral isopter
5. Superimposition of static field
39. Automated Kinetic Perimeters
6. Superimposition of visual field and fundus image
7. Underlay fundus image
8. Underlay previous fields
9. Create an automated examination
10. Run an automatic examination
40. Negative aspect of static testing
About 30% of all highly pathological patients cannot be tested
with static perimetry. Part of the problem is that the reliability
of the test is not guaranteed because of the variability of the
answers the patients will give.
41. Disclosure
Author does not have any financial or trade interest in any of
the companies instruments of which are mentioned presentation
42. Advantages of OCTOPUS computer assisted Goldmann kinetic
perimetry
1:1 Goldmann Functionality
Patented Reaction time compensation
Resolution down to 0.1 enabling to accurately test the blind
spot
Calculation of isopter and scotoma areas
Automatic retest of once established kinetic field
Superposition of static field
True full field perimeter
Produces comparable results
Quick transition from traditional Goldmann
43. Studies in favour of Kinetic Perimetry
44. The use of semi-automated kinetic perimetry (SKP) to
monitor advanced glaucomatous visual field loss Graefe's Archive
for Clinical and Experimental Ophthalmology Volume 246, Number 9 /
September, 2008 Pages 1331-1339 J.Nevalainen, J.Paetzold, E.Krapp,
R.Vonthein, C.A.Johnson and U.Schiefer
45. Purpose and Conclusions
Purpose (i) To compare visual field (VF) results obtained with
semi-automated kinetic perimetry (SKP) and automated static
perimetry (ASP) in patients with advanced glaucomatous VF loss,
(ii) to evaluate test-retest reliability of SKP and ASP and (iii)
to assess patients preference for SKP and ASP.
Conclusions The comparability between SKP and ASP is
satisfactory and within the range of the test-retest reliability of
ASP . SKP shows slightly better test-retest reliability than ASP.
The majority of patients with advanced glaucomatous visual field
loss prefer SKP instead of ASP . SKP is a valuable alternative to
ASP in monitoring advanced glaucomatous visual field loss.
46. Comparison between semiautomated kinetic perimetry and
conventional goldmann manual kinetic perimetry in advanced visual
field loss NOWOMIEJSKAKatarzyna (1 2) ; VONTHEINReinhard (3) ;
PAETZOLDIens (1) ; ZAGORSKIZbigniew (2) ; KARDONRandy (4) ;
SCHIEFERUlrich (1) ; Ophthalmology ISSN0161-6420 CODENOPHTDG Source
/ Source 2005,vol.112,no8,pp.1343-1354[12 page(s) (article)](29
ref.)
47. Purpose and Conclusions
Purpose: To compare quantitatively visual field (VF) results
obtained using a new standardized semiautomated kinetic perimetry
(SKP) with those obtained by conventional Goldmann manual kinetic
perimetry (MKP) in patients with advanced VF loss.
Conclusions: Their results indicated that SKP isopter shape and
size were very comparable to those obtained on the same eyes with
MKP. Semiautomated kinetic perimetry may represent a more
standardized method of kinetic perimetry, which still takes
advantage of perimetrist-patient interaction to diagnose and
monitor advanced VF loss in clinical practice.
48. Kinetic perimetry Author: SHIKISHIMA KEIGO (Fac. Medicine,
Jikei Univ. School of Medicine, JPN) Ophthalmology VOL.48; NO.10;
PAGE.1433-1438 (2006)
49. Conclusions
The test result with GP were more reliable than one with the
automated perimeter in cases of old people and of poor visual
acuity . Also, it was superior in pattern recognition of the visual
field, detection of psychogenic visual field abnormality, grasp of
a peripheral part of visual field and evaluation of visual
abnormality depending on whether the visual field is in line with
meridian or not.
In addition, the points to be kept in mind in interpretation of
abnormal visual fields including Riddoch phenomenon , factors which
affect abnormal perimetry and psychogenic visual field abnormality
are described.
50. A Comparison of Semiautomated Versus Manual Goldmann
Kinetic Perimetry in Patients With Visually Significant Glaucoma.
Original Studies Journal of Glaucoma. 17(2):111-117, March 2008.
Ramirez, Adriana M. MD *; Chaya, Craig J. MD +; Gordon, Lynn K. MD,
PhD * ++; Giaconi, JoAnn A. MD * ++
51. Purpose and Conclusions
Purpose: To determine if semiautomated kinetic perimetry (SKP)
is reproducible and comparable to Goldmann manual kinetic perimetry
(GVF).
Conclusions: SKP and GVF testing produced similar visual field
results in glaucoma patients, and SKP testing seems to be reliable
and reproducible in this population. However, overlapping isopters,
typically associated with nonorganic vision loss, and jagged
isopters were sometimes observed in SKP visual fields. Further
study of SKP is needed to explore these findings.
52. I have tested for you. Automated kinetic perimetry
Publication Type: Comparative Study; English Abstract; Journal
Article Journal: Journal franais d'ophtalmologie (J Fr Ophtalmol).
Reference: 2006-May; vol 29 Spec No 2 (issue ) : pp 36-9 PMID:
17072220 (status: MEDLINE) (last retrieval date: 12/12/2007)
53. Conclusions
Authors compared the kinetic perimetry of the Humphrey Field
Anayzer and the Haag Streit Octopus 101 and assessed their use in
relation to Goldmann perimetry. The Humphrey kinetic perimetry
comes close to Goldmann perimetry and the Octopus shows clear
advantages, notably in terms of ergonomics and its more
sophisticated software. The Goldmann requires a high level of
skill; examination time with the Humphrey and the Octopus is at
least double the time required by a skilled Goldmann operator.
54. Conclusions Contd
The examiner can to a certain degree be passive during the
static visual field examination, but is entirely active during the
kinematic visual field examination. Therefore, contrary to static
perimetry, the examination can only be performed by a physician.
The future of automated kinematic perimetry depends on
simplification of the software.
55. Computerized kinetic perimetry detects tubular visual
fields in patients with functional visual loss American Journal of
Ophthalmology Volume 137, Issue 5, May 2004, Pages 933-935 Stacy L.
Pineles BSE and Nicholas J. Volpe MD
56. Conclusions
This test used a computerized kinetic examination to reduce the
subjective nature of tangent screen testing for tubular visual
fields and to provide a computerized recording of visual fields.
This method is a novel and easy-to-use technique to demonstrate
functional visual loss.
Goldmann Kinetic perimetry in manual, semi-automatic and
automatic modes.
30 threshold test in 2.5 minutes
Octopus "No Fixation Loss" technology provides actionable data
for doctors
60. OCULUS CenterField Perimeter
Finally, a Compact 70 Static/Kinetic/Colour Perimeter The
Centerfield automatically performs static and kinetic perimetry in
a 36 visual field. Expands to 70 with a fixation shift. Offers
white /white and blue /yellow colour perimetry. Screening. Supra,
fast, and normal threshold measurements. Popular 30-2, 24-2, and
10-2 grids. That's Incredibly Precise Designed to the Goldmann
standard
61. COMPARISON OF AUTOMATED KINETIC AND STATIC VISUAL FIELDS IN
NEURO-OPHTHALMOLOGY PATIENTS Perimetry Update 1988/89, pp. 3-8
Proceedings of the VIIIth International Perimetric Society Meeting
edited by A Heijl Kugler & Ghedini Publications, Amsterdam,
Berkeley, Milan
62. Conclusions
Eighty-three patients with various neuro-ophthalmic diseases
were submitted to a standard automated protocol including kinetic
and static perimetry
The results of this study indicated that the ideal evaluation
of neuro-ophthalmology patients should include complete kinetic and
static fields. Both examinations present significant advantages,
namely, the static examination assesses more precisely the volume
of large paracentral scotomas and the kinetic examination is more
sensitive and reliable for the detection of relative scotomas at
eccentricities of over 15 degrees.
63. Humphrey HFAII -i Field Analyzer. Precision and less time.
Exactly as Goldmann specified The HFA II- i Field Analyzer meets
all requirements for state-of-theart static and kinetic
perimetry.
64. Goldmann Kinetic Perimeter
65. Difficult Cases for Kinetic Perimetry
Cases of early qualitative changes
66. Difficult Cases for Static Perimetry
Advanced field changes found in cases of glaucoma
Hemianoptic visual field changes seen in cases of neurological
disorders
67. Superposition of VF and fundus image
Superimposition of visual field on colored fundus photograph is
possible for better interpretation
A
68. SUPERIMPOTION OF STATIC FIELDS
Superimposition of static visual field is possible on kinetic
visual field for better interpretation
69. Summary
Static and Kinetic perimetry, both record visual fields and
have their place in evaluation of cases of Glaucoma, neurological
and retinal disorders.
There are some cases where static perimetry may be difficult,
like cases of advanced glaucomatous field defects, neurological
diseases and retinal vascular diseases.
The major disadvantage of kinetic perimeters i.e. lack of
standardization has been rectified with automated kinetic
perimeters