1. 시야검사의 이해
서울성모병원
안 명 덕

2. Kinetic vs Static Perimetry
Kinetic perimetry
moving the test object from a nonseeing (subthreshold)
to a seeing (suprathreshold)
: recording the point at which it is first seen
isopters (boundaries or contour lines)
Static perimetry (supratheshold and threshold)
Suprathreshold : on-off technique against presumed stimulus
: screening test
Threshold : relative intensity thresholds
: increasing vs decreasing method

3. Physiologic factors that influence VF
Pupil size
Significant miosis
: depress central and pph threshold sensitivities and exaggerate
field defects
Mydriasis : less influence
recommend : >3mm
Age
reduction of retinal threshold sensitivity
: pph and sup. area neuronal loss
Clarity of ocular media
cataract : central or pph field defects
corneal disturbance, PCO, vitreous opacities : affect VF

4. Physiologic factors that influence VF
Refractive error and retinal blur
refractive error : influence central VF
correction
myopia (-3D~)
hyperopia
Astigmatism (0~-1D : SE, -1D~ : cylinder lens)
Aphakic and highly myopic : CL
Psychologic factors
patient’s understanding
learning effect
fatigue effect

5. Humphrey Patient data Reliability Indices GHT
Total deviation decibel plot
Global
Indices
Numerical or gray symbol 많은 점 검사할 수록 더 많은 결손 부위가 나타난다. 80군데 이상하면 피곤,
Total deviation probability plot
Pattern deviation probability plot
Gaze tracking graph

6. Interpreting the results and analyzing progression
Determining test reliability
Short-term fluctuation
Difference between the responses at the same location during the same session
Long-term fluctuation
Difference in threshold values in the same location between separate
sessions
녹내장 환자의 장기기복이 정상인보다 크므로 시야장애 변화 확인 위해서
는 적어도 3회 이상의 검사가 필요, 2회 시야 검사의 평균 감도가 5 dB 이
상 차이가 있을 경우 반복 측정 필요
False-positives (Ex. >33% in Full threshold or 15% in SITA => reliability↓)
False-negatives (Ex. >33% in Full threshold or 15% in SITA => reliability↓)
Fixation loss (Ex. >20% in Heijl-Krakau technique => reliability↓XX)
Number of stimulus (Ex. > 550 in Humphrey 30degree=> reliability↓)
Test duration (Ex. >18 min in Humphrey 30degree=> reliability↓)

7. Interpreting the results and analyzing progression
Global Indices
Mean deviation (MD)
Average of all points in the total deviation
increase : media opacity, diffuse or severe localized
loss sensitive to progression of field loss
Pattern standard deviation (PSD)
Detect localized defects, irregularity of VF
Calculate the number of threshold values that deviate significantly from the age-corrected normal
Corrected pattern standard deviation (CPSD)
Adjusted by short-term fluctuations

8. Interpreting the results and analyzing progression
Glaucoma hemifield test (GHT)
Compare sums of threshold values between superior and inferior hemispheres
Total deviation
decibel plot

9. Glaucoma hemifield test
1) “Within normal limits” : no significant difference between the sup. and inf. halves. : overall sensitivity is within 99.5% range of normal 2) “Outside normal limits” : threshold difference between the sup. and inf. halves of the fields are greater than 99% 3) “Borderline” : threshold difference are greater than would be in 97% 4) “General reduction of sensitivity” : overall sensitivity below the 99.5% range of normal : no significant difference between the sup. and inf. halves 5) “Abnormally high sensitivity” : overall sensitivity is higher than in 99.5% of normal : high false-positive rate

10. Glaucomatous visual field defect
Minimal criterias for glaucomatous damage (Anderson’s criteria)
: one of the following defects on Humphrey visual field test
Glaucoma hemifield test : outside normal limits on at least two consecutive occasions
Cluster of three or more none-edge points (Pattern Deviation)
: all at p<5% and one of which at p<1% in expected location
on HVF24
CPSD : less than 5% on two consecutive fields
should be confirmed on a second test
Grading of glaucomatous damage
Mild : MD <- 6dB
Moderate : MD <- 12dB
Severe : MD >-12dB
End stage
Numerical or gray symbol 많은 점 검사할 수록 더 많은 결손 부위가 나타난다. 80군데 이상하면 피곤,

11. Paracentral
scotoma
Nasal step

12. Altitudinal
scotoma
Double arcuate
scotoma

13. Practicalities on VF exam(EGS, IInded)
The first tests should be considered with caution or discarded
(learning effect)
To be clinically significant, VF defect must be confirmed on
repeated exams
Media opacity and miotic pupils worsen MD
Disc features must match VF defects
Rule out other ocular causes of VF defects

14. Identification of progressive glaucomatous VF loss
Separating real change from ordinary variation
test variability … difficult challenge
glaucoma → ↑
General decrease in sensitivity
progression or media opacity (miosis, cataract) ??
Fundamental requirement : good baseline VF
at least two VFs
Less frequent test → chances of identifying change ↓
Repeated for confirmation

15. Progression guidelines (AAO, 2004)
Deepening
Reproducible depression of a point by ≥ 7 dB
Enlargement
≥ 9 dB
New scotoma
A previously normal point by ≥ 11 dB
Two adjacent, previously normal points by ≥ 5 dB

16. Current methods Clinical judgment Defect classification systems
the oldest method
subjectivity
“overview printout”
Defect classification systems
AGIS and CIGTS
easily defined as worsening of score over time
lack of score change
: not rule out small progression
time consuming

17. Current methods Trend analysis Event analysis
test parameters sequentially
linear regression analysis MD
Pointwise threshold data
Event analysis
Identify single events of significant change relative to reference exam
Glaucoma Change Probability Analysis (GCPA)
Glaucoma Progression Analysis (GPA)

18. 60 / M OS) POAG : disc hemorrhage & progression① ② ④ ③

19. Overview printout

20. Change analysis

21. Other types of perimetry
Frequency Doubling Perimetry (FDT)
Short Wavelength Automated Perimetry (SWAP)
Microperimetry

22. Preperimetric Glaucoma
FDT

23. FDT and SWAP to detect Early Glaucoma
Detection of
glaucomatous visual field loss
3 ~ 5 years early than SAP
1 ~ 2 years early than SAP
Number of ganglion cells in glaucoma eyes compared with threshold visual field tests in the same persons.
Invest Ophthalmol Vis Sci 2000;41:741– 8.
The “blue-on” opponent pathway in primate retina originates from a distinct bistratified ganglion cell type.
Nature 1994;367:731–5.
Blue-onyellow perimetry can predict the development of glaucomatous visual field loss.
Arch Ophthalmol 1993;111:645–50.
Short Wavelength Automated Perimetry, Frequency Doubling Technology Perimetry, and Pattern Electroretinography for Prediction of Progressive Glaucomatous Standard Visual Field Defects.
Ophthalmology 2002;109:1009–1017

24. : more sensitive, can detect VF loss and
FDT & SWAP
: more sensitive, can detect VF loss and
progression earlier than SAP
Consensus criteria for abnormality lacking
Consensus criteria for progression lacking
FDT
Test time less than 1 min
Portable
Good patient acceptance
Less practice dependent than SAP (no learning effect)
Lower inter- and intra-test variability, short term variability
Detect early glaucomatous defects
Successfully used to test children
Unaffected by defocus
SWAP
Early detection of glaucoma and progression
Presence of learning effect
Intra- and inter-test variability higher, greater short term variability
Affected by media opacity
More fatigue for patients than SAP

25. 감사합니다.