Kinetic perimetry


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Kinetic perimetry

  1. 1. 31 January 2015 Prof Sanjay Shrivastava 1 Power point copy of talk presented at 32nd M.P. State Ophthalmic Conference held from 17th to 19th October 2008 at Ujjain
  2. 2. Kinetic Perimetry Dr Sanjay Shrivastava Professor of Ophthalmology Regional Institute of Ophthalmology Gandhi Medical College, Bhopal
  3. 3. 31 January 2015 Prof Sanjay Shrivastava 3 Visual Field • The Normal visual field is depicted as Traquair’s “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. 4. 31 January 2015 Prof Sanjay Shrivastava 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. 5. 31 January 2015 Prof Sanjay Shrivastava 5 Influence of Glaucoma on Visual Function o Understanding about natural history of progressive visual field loss is continuously increasing with newer instruments and technologies which has increased the sensitivity of test o 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. 6. 31 January 2015 Prof Sanjay Shrivastava 6 Influence of Glaucoma on Visual Function o Studies have shown that mild central and diffuse reduction in the visual field can occur even in early stage of glaucoma
  7. 7. 31 January 2015 Prof Sanjay Shrivastava 7 Visual Field defects in Glaucoma o Concentric contraction o Enlargement of blind spot o Angioscotoma o 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. 8. 31 January 2015 Prof Sanjay Shrivastava 8 Visual Field defects in Glaucoma b. Arcuate defect c. Nasal step d. Vertical step e. Temporal sector defect
  9. 9. 31 January 2015 Prof Sanjay Shrivastava 9 Other Conditions Affecting Visual Field • Neurological Disorders • Retinal Diseases including pigmentary dystrophies and vascular diseases
  10. 10. 31 January 2015 Prof Sanjay Shrivastava 10 Advanced Glaucomatous Field Defects o Complete double arcuate scotoma with extension to peripheral limits in all areas except temporally o This results in a central island and a temporal island of vision in advanced glaucoma
  11. 11. 31 January 2015 Prof Sanjay Shrivastava 11 Other Measures of Visual Impairment in Glaucoma
  12. 12. 31 January 2015 Prof Sanjay Shrivastava 12 Other Measures 1. Colour vision 2. 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. 13. 31 January 2015 Prof Sanjay Shrivastava 13 Techniques of Visual Field Analysis
  14. 14. 31 January 2015 Prof Sanjay Shrivastava 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. 15. 31 January 2015 Prof Sanjay Shrivastava 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. 16. 31 January 2015 Prof Sanjay Shrivastava 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. 17. 31 January 2015 Prof Sanjay Shrivastava 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. 18. 31 January 2015 Prof Sanjay Shrivastava 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. 19. 31 January 2015 Prof Sanjay Shrivastava 19 Kinetic Perimetry o Boundaries or contour lines are called isopters. The size of isopter depends on the stimulus value of the test object o Kinetic targets: a stimulus velocity of 4 degree per second appears to be optimal for all targets in the central and peripheral visual field o 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. 20. 31 January 2015 Prof Sanjay Shrivastava 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. 21. 31 January 2015 Prof Sanjay Shrivastava 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. 22. 31 January 2015 Prof Sanjay Shrivastava 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. 23. 31 January 2015 Prof Sanjay Shrivastava 23 Manual Perimetry o 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. 24. 31 January 2015 Prof Sanjay Shrivastava 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. 25. 31 January 2015 Prof Sanjay Shrivastava 25 Automated Perimetry • The first era of perimetry – mid 19th century, the work of von Graefe provided Tangent Screens and Arc perimeters. • They were lacking standardization • In middle 20th century Goldmann perimeter brought standardization • The problem of subjectivity of both patient and perimetrist remained
  26. 26. 31 January 2015 Prof Sanjay Shrivastava 26 Automated Perimetry o The problem of subjectivity of perimetrist was eliminated by automation which began in the 1970s o Automated perimetry improved the uniformity and reproducibility of visual fields o 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. 27. 31 January 2015 Prof Sanjay Shrivastava 27 Automated Perimetry o Automated perimetry is more accurate and informative (but it is neither fast nor cheap)
  28. 28. 31 January 2015 Prof Sanjay Shrivastava 28 Factors Influencing Field o 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. 29. 31 January 2015 Prof Sanjay Shrivastava 29 Influence of moving spot o 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. 30. 31 January 2015 Prof Sanjay Shrivastava 30 Neurological types of field defects 1. Prechiasmal defects 2. Chiasmal defects 3. Postchiasmal defects
  31. 31. 31 January 2015 Prof Sanjay Shrivastava 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. 32. 31 January 2015 Prof Sanjay Shrivastava 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. 33. 31 January 2015 Prof Sanjay Shrivastava 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. 34. 31 January 2015 Prof Sanjay Shrivastava 34 Why is Goldmann Kinetic Perimetry so important o 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. 35. 31 January 2015 Prof Sanjay Shrivastava 35 Kinetic Perimetry o 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. 36. 31 January 2015 Prof Sanjay Shrivastava 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. 37. 31 January 2015 Prof Sanjay Shrivastava 37 Shortcomings of traditional Goldmann kinetic perimetry o Regular training of examiner is reflected in the quality of the result o Regular manual calibration of the instrument required o Quality guidelines recommended (Standard set of parameters, Verification of the blind spot, Surveillance of the eye)
  38. 38. 31 January 2015 Prof Sanjay Shrivastava 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. 39. 31 January 2015 Prof Sanjay Shrivastava 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. 40. 31 January 2015 Prof Sanjay Shrivastava 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. 41. 31 January 2015 Prof Sanjay Shrivastava 41 Disclosure • Author does not have any financial or trade interest in any of the companies instruments of which are mentioned presentation
  42. 42. 31 January 2015 Prof Sanjay Shrivastava 42 Advantages of OCTOPUS computer assisted Goldmann kinetic perimetry o 1:1 Goldmann Functionality o Patented Reaction time compensation o Resolution down to 0.1° enabling to accurately test the blind spot o Calculation of isopter and scotoma areas o Automatic retest of once established kinetic field o Superposition of static field o True full field perimeter o Produces comparable results o Quick transition from traditional Goldmann
  43. 43. 31 January 2015 Prof Sanjay Shrivastava 43 Studies in favour of Kinetic Perimetry
  44. 44. 31 January 2015 Prof Sanjay Shrivastava 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. 45. 31 January 2015 Prof Sanjay Shrivastava 45 Purpose and Conclusions o 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. o 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. 46. 31 January 2015 Prof Sanjay Shrivastava 46 Comparison between semiautomated kinetic perimetry and conventional goldmann manual kinetic perimetry in advanced visual field loss NOWOMIEJSKA Katarzyna (1 2) ; VONTHEIN Reinhard (3) ; PAETZOLD Iens (1) ; ZAGORSKI Zbigniew (2) ; KARDON Randy (4) ; SCHIEFER Ulrich (1) ; Ophthalmology ISSN 0161-6420 CODEN OPHTDG Source / Source 2005, vol. 112, no8, pp. 1343-1354 [12 page(s) (article)] (29 ref.)
  47. 47. 31 January 2015 Prof Sanjay Shrivastava 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. 48. 31 January 2015 Prof Sanjay Shrivastava 48 Kinetic perimetry Author: SHIKISHIMA KEIGO (Fac. Medicine, Jikei Univ. School of Medicine, JPN) Ophthalmology VOL.48; NO.10; PAGE.1433-1438 (2006)
  49. 49. 31 January 2015 Prof Sanjay Shrivastava 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. 50. 31 January 2015 Prof Sanjay Shrivastava 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. 51. 31 January 2015 Prof Sanjay Shrivastava 51 Purpose and Conclusions o Purpose: To determine if semiautomated kinetic perimetry (SKP) is reproducible and comparable to Goldmann manual kinetic perimetry (GVF). o 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. 52. 31 January 2015 Prof Sanjay Shrivastava 52 I have tested for you. Automated kinetic perimetry Publication Type: Comparative Study; English Abstract; Journal Article Journal: Journal français 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. 53. 31 January 2015 Prof Sanjay Shrivastava 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. 54. 31 January 2015 Prof Sanjay Shrivastava 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. 55. 31 January 2015 Prof Sanjay Shrivastava 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. 56. 31 January 2015 Prof Sanjay Shrivastava 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.
  57. 57. 31 January 2015 Prof Sanjay Shrivastava 57 GKP Goldmann Kinetic Perimetry Instruction Manual HS# 1802025 © Haag-Streit AG (Rev 4, 01/2006) Haag-Streit AG Gartenstadtstrasse 10, 3098 Köniz/Bern, Switzerland Telefon: ++41 31 978 0111, Fax: ++41 31 978 0282, E-Mail:,
  58. 58. 31 January 2015 Prof Sanjay Shrivastava 58 Octopus 900® Full-Field Goldman Perimeter All-In-One Perimeter, Kinetic Perimetry, Customized Tests —
  59. 59. 31 January 2015 Prof Sanjay Shrivastava 59 Octopus 900® Full-Field Goldman Perimeter • 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. 60. 31 January 2015 Prof Sanjay Shrivastava 60 OCULUS CenterField Perimeter • Finally, a Compact 70º Static/Kinetic/Colour Perimeter The Centerfield automatically performs static and kinetic perimetry in a 36º visual field. Expands to 70º 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. 61. 31 January 2015 Prof Sanjay Shrivastava 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. 62. 31 January 2015 Prof Sanjay Shrivastava 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. 63. 31 January 2015 Prof Sanjay Shrivastava 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. 64. 31 January 2015 Prof Sanjay Shrivastava 64 Goldmann Kinetic Perimeter
  65. 65. 31 January 2015 Prof Sanjay Shrivastava 65 Difficult Cases for Kinetic Perimetry • Cases of early qualitative changes
  66. 66. 31 January 2015 Prof Sanjay Shrivastava 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. 67. 31 January 2015 Prof Sanjay Shrivastava 67 Superposition of VF and fundus image • Superimposition of visual field on colored fundus photograph is possible for better interpretation A
  68. 68. 31 January 2015 Prof Sanjay Shrivastava 68 SUPERIMPOTION OF STATIC FIELDS • Superimposition of static visual field is possible on kinetic visual field for better interpretation
  69. 69. 31 January 2015 Prof Sanjay Shrivastava 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
  70. 70. 31 January 2015 Prof Sanjay Shrivastava 70 Thank you