1. Octopus & Goldmann Kinetic Perimetry
2009
Matthias Monhart
Product Manager

2. The instructor has a financial interest in the subject
Octopus & Goldmann
Kinetic Perimetry
Matthias J. Monhart
Engineer FH (BSc)
in Electronics, Measurement and Control Product Specialist in Perimetry
HAAG-STREIT AG
The instructor has a financial interest in the subject

3. Kinetic Perimetry  Principle  Examination  Results
Agenda
Kinetic Perimetry  Principle  Examination  Results

4. Standard W/W Perimetry
Role of Perimetry
Application fields
Progression of the disease
Onset
End stage
Methods
Standard W/W Perimetry
Low Vision Strategy Kinetic perimetry
HFA 10-2
Functional Test:
B/Y-SWAP, FDT, Flicker
Structural Test:
Stereo Fundus-Photography Imaging (HRT, OCT, GDX)
From the onset of the disease till the end stage different diagnostic methods need to be applied to follow the patient over time.
With the combination of Flicker, SWAP, W/W Standard Perimetry, Low Vision Programs and true Goldmann Kinetic the Octopus 900 covers the whole spectrum from the onset to the end stage of the disease.

5. Anatomy of the eye Hill-of-vision Sensitivity distribution in the eye:
Sensitivity drops steeply towards the periphery
In the macula, there is a sensitivity peak.
Shown here is a normal visual field together with a depressed (pathological) hill of vision.

6. Static or Kinetic Perimetry
Application fields
Cross section through the hill-of-vision
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.
Kinetic perimetry is ideal for the periphery and deep local defects.
As mentioned before, the shape of the hill-of-vision makes it clear that the two methods complement each other in the optimum description of the hill-of-vision.

7. Kinetic Perimetry Isopters
Multiple responses connect to one isopterline (Line of equivalent sensitivity)

8. Theoretic eccentricity
Kinetic Perimetry
Theoretic eccentricity
Stimulus size III and the maximum Intensity (4e) in an average normal subject yield these eccentricities.
The normal periphery detectable with the relevant parameters for expert opinion reflect the range visible for a healthy subject, limited only by the physiology of the head examples are the nasal inferior quadrant limited by he nose and the temporal inferior quadrant extending up to 105°. OS OD

9. Practical eccentricity
Kinetic Perimetry
Practical eccentricity
The effective limitations deal with the individual physiology (nose, forehead, eye brows) and the size/shape of the cupola and limitations of the projector.

10. Instruments: Goldmann
Kinetic Perimetry
Instruments: Goldmann
Prof. Hans Goldmann invented the Haag-Streit Goldmann Perimeter and set the standard for kinetic perimetry since 1945.

11. Goldmann Perimetry
“Drawing” the test

12. Octopus 101 GKP
“Drawing” in Windows

13. Octopus 900 Goldmann
“Drawing” in Windows

14. Goldmann Examination 1. Prepare the form
So let us see what the basic procedures is to receive a Goldmann field. First we start with the empty template that is being clamped under the pantograph of the Goldmann perimeter. Wherever the pantograph is moved on this template, the stimulus light will be presented in the cupola. This sheet is used to note the examination results and truly draw the visual field from isopter lines.

15. Goldmann Examination 2. Stimulus intensity
Stimulus size Octopus I..V
Stimulus-Intensity 4,3,2,1 in 5dB steps Stimulus-Intensity a,b,c,d,e in 1dB steps
Maximum 4e = 0dB = 1000asb
Minimum 1a = 19dB = 13asb
When the instrument is prepared and the patient is instructed, the test parameters need to be set. For the definition of test parameters in the Goldmann perimeter characters, roman and arabic numbers are used. A combination of arabic number and character reflects a certain intensity. From the dimmest stimulus (1a) to the brightest (4e) the intensity is increased in 1dB steps from one character to the next and in 5dB steps from 1 arabic number to the next.

16. Goldmann Examination 3. Stimulus size Blind spot location:
Comparison of stimulus size III with the sensitivity map of the blind spot (approx. 5° Horizontal, 6° Vertical)
Blind spot location:
X = +15° for OD, -15° for OS Y = -1° for OS and OD
Recommendations
I Blind spot, scotoma
III Periphery
V End stage / remaining vision
But how do the stimulus sizes relate to the retina? This best can be seen when comparing to the blind spot, the notch in the hill of vision where the optic nerve enters the eye. Stimulus size III has a diameter of about 1/10 of the diameter of the blind spot.

17. Goldmann Examination 4. Patient information
Identification of Patients:
Examination date:
Pupil diameter
Small pupils influence the isopter size
OS: left eye OD: right eye Use near correction for isopters and testing within 30°
Basic to the examination of course are the identification of the patient, the date and time of the examination to allow to identify changes over time. Then the pupil diameter - as small pupil diameters may „shrink“ the isopters. In addition – if we examine the center 30° - we need to correctly refract the patient to see focused at the 30cm distance where the lights appear. This is important as the accuracy of the results decreases if the patient has difficulty to focus on the fixation target and scotoma boarders „wash out“.

18. Goldmann Examination 5. “Drawing” the exam
„Drawing“ of the examination on the Goldmann form
The red areas can actually not be examined in the original Goldmann perimeter as those areas are cut out in the cupola and used for the projector. Thus our example in the original Goldmann could only show a response further to the center, outside the red area.

19. Goldmann Perimetry Limitations
Only coarse calibration of stimulus and background intensities
Quality influenced by experience
Limited Repeatability
Different standards in every clinic
But while static automated perimetry is said to be as easy as (though we know there is more to it too) Goldmann kinetic Perimetry requires a high level of skills already to start with.

20. From manual to computer
assisted kinetic perimetry
The pantograph is replaced by the mouse
While it can be shown that kinetic perimetry has an important role in diagnosing and following diseases, it has become clear that the purely manual Goldmann type perimeters also have many drawbacks. Octopus started the implementation of kinetic perimetry to automated perimeters in Today‘s implementation is the third generation, profiting from our long experience and an intensive cooperation with Professor Ulrich Schiefer of the University eye clinic in Tuebingen. The implementation combines controllable and repeatable parameters available in automated perimeters with the expertise of the perimetrist concluding the test. Even moving the stimulus pantograph-like „by hand“ using the mouse or an optional pen display is possible.

21. From manual to computer
assisted kinetic perimetry
The template „travels“ to the screen
The Octopus has the widest testable field on the market (X+/-89.5°,Y+60/-70°), superior to Humphrey (X<80°/Y~+50/-60°) and Oculus Twinfield. Octopus Goldmann Kinetic Perimetry is based on age matched normal values from a normal value study in the University of Tuebingen allowing to display normal isopter rings.
Octopus shows age matched norms for orientation

22. From manual to computer
assisted kinetic perimetry
Near correction for points (isopters) < 30°
same principle as in static perimetry
Goldmann und Octopus 900 (30cm)
30-40J +1.0
40-45J +1.5
45-50J +2.0
50-55J +2.5
55-60J +3.0
>60J
Octopus 101 GKP (42.5cm)
40-44J +1.0
45-49J +1.25
50-54J +1.75
>
Same refraction for presbyopia as in the Octopus 900 as in the original Goldmann

23. From manual to computer
assisted kinetic perimetry
Stimulus size and -intensity
In order to facilitate the transition from orthoptists working with the traditional Goldmann perimeter to Octopus GKP, the familiar elements as the selection of stimulus size and intensity remained unchanged. Also the way stimuli and kinetic vectors are drawn on the working surface have been implemented as close as possible to the original Goldmann.
Goldmann
Octopus 101
Octopus 900

24. From manual to computer
assisted kinetic perimetry
Preset of constant velocities
Constant velocities result in better reproducible test results Recommendation <30°: 2°/Sec. >30°: 5°/Sec.

25. Octopus Goldmann Kinetic
Advantages
Automatic and accurate calibration
Good quality exams based on constant velocities / stimulus movements
Automatic repetition of examination allows for follow up
General standards can more easily be applied and exchanged

26. Octopus Goldmann Kinetic
Vector types
Vectors define the path a stimulus moves
Test vectors for general examination
Guided vectors for special conditions, like the nasal step, where still a constant velocity shall be maintained

27. Octopus Goldmann Kinetic
Reaction time compensation
stimulus visible
corrected response
response button pushed
The RT (Reaction Time) vector must be visible right from the start. The delay in response to an RT vector can be compensated in regular responses.

28. Octopus Goldmann Kinetic
Possible early responses
Only in Octopus 101:
A perpendicular line at the beginning of the vector indicates an early response. This means, it might have been seen from the start – or – the patient did produce a false positive response.
The perpendicular line in the vector start indicates an early response. This may indicate a false positive or a vector that has been seen from the beginning.

29. Octopus Goldmann Kinetic
Fluctuation
Fluctuation:
Response fluctuation exists in kinetic perimetry just the same as in static perimetry. Repeating vectors lead to responses that vary to a certain extent.
Short term fluctuation leads to slightly different responses every time the same vector is presented.

30. Octopus Goldmann Kinetic
Examination procedure
Search for scotoma with static points
Stimulus I4e, 0°/Sec. (static), Example blind spot
There is a saying that a good perimetrist can smell a scotoma. And I would even say this is true for good perimetrists whether they examine with static or kinetic perimetry. But while there is not much influence to take in static perimetry besides choosing the appropriate program and strategy, the examination procedure in Goldmann kinetic is purely manual. Therefore different schemes exist and the one explained here is just an example. It is based on a quick assessment of the general conditions in each quadrant, a confirmation of the fixation stability and quality and a continuation of the examination that is strongly relating to the visual field and the subjects abilioties to cooperate with the perimetrist.
1. search horizontal extent
2. search vertical extent

31. Octopus Goldmann Kinetic
Examination procedure
Define the size and shape with kinetic vectors
Stimulus I4e, 2°/Sec., example blind spot
There is a saying that a good perimetrist can smell a scotoma. And I would even say this is true for good perimetrists whether they examine with static or kinetic perimetry. But while there is not much influence to take in static perimetry besides choosing the appropriate program and strategy, the examination procedure in Goldmann kinetic is purely manual. Therefore different schemes exist and the one explained here is just an example. It is based on a quick assessment of the general conditions in each quadrant, a confirmation of the fixation stability and quality and a continuation of the examination that is strongly relating to the visual field and the subjects abilioties to cooperate with the perimetrist.
Draw vectors from inside of a scotoma to outside
Vectors are placed starting in non-seeing area and ending in seeing area, ideally perpendicular to the border of the scotoma or visual field border

32. Octopus Goldmann Kinetic
Examination procedure
Reaction time testing and compensation
Stimulus I4e, 2°/Sec., example around the blind spot:
There is a saying that a good perimetrist can smell a scotoma. And I would even say this is true for good perimetrists whether they examine with static or kinetic perimetry. But while there is not much influence to take in static perimetry besides choosing the appropriate program and strategy, the examination procedure in Goldmann kinetic is purely manual. Therefore different schemes exist and the one explained here is just an example. It is based on a quick assessment of the general conditions in each quadrant, a confirmation of the fixation stability and quality and a continuation of the examination that is strongly relating to the visual field and the subjects abilioties to cooperate with the perimetrist.
RT-Vectors have to be visible all the time, they thus must start in areas of preserved vision.
Responses on the right side include reaction time compensation.

33. Octopus Goldmann Kinetic
Manual operation
The operation of the Goldmann pantograph can be reproduced by moving the mouse.
Stimulus I4e, „free“, example of manual spiraling at the blind spot:
0-1°/sec black
2-3°/sec blue
4-7°/sec green
≥ 8°/sec red
There is a saying that a good perimetrist can smell a scotoma. And I would even say this is true for good perimetrists whether they examine with static or kinetic perimetry. But while there is not much influence to take in static perimetry besides choosing the appropriate program and strategy, the examination procedure in Goldmann kinetic is purely manual. Therefore different schemes exist and the one explained here is just an example. It is based on a quick assessment of the general conditions in each quadrant, a confirmation of the fixation stability and quality and a continuation of the examination that is strongly relating to the visual field and the subjects abilioties to cooperate with the perimetrist.
Drawing spirals is one method of searching remaining vision

34. Octopus Goldmann Kinetic
Examination procedure
Setting anchor vectors to judge the quadrants
Stimulus III4e (oder III3e), 5°/Sec., example quadrantanopia
There is a saying that a good perimetrist can smell a scotoma. And I would even say this is true for good perimetrists whether they examine with static or kinetic perimetry. But while there is not much influence to take in static perimetry besides choosing the appropriate program and strategy, the examination procedure in Goldmann kinetic is purely manual. Therefore different schemes exist and the one explained here is just an example. It is based on a quick assessment of the general conditions in each quadrant, a confirmation of the fixation stability and quality and a continuation of the examination that is strongly relating to the visual field and the subjects abilioties to cooperate with the perimetrist.
Vectors towards the center (Meridians) on 45,135,225 and 315° from outside to inside the normal range.

35. Octopus Goldmann Kinetic
Examination procedure
Outlining a quadrantanopia
There is a saying that a good perimetrist can smell a scotoma. And I would even say this is true for good perimetrists whether they examine with static or kinetic perimetry. But while there is not much influence to take in static perimetry besides choosing the appropriate program and strategy, the examination procedure in Goldmann kinetic is purely manual. Therefore different schemes exist and the one explained here is just an example. It is based on a quick assessment of the general conditions in each quadrant, a confirmation of the fixation stability and quality and a continuation of the examination that is strongly relating to the visual field and the subjects abilioties to cooperate with the perimetrist.
Best accuracy is given when vectors cross the scotoma borders perpendicularly

36. Octopus Goldmann Kinetic
Examination procedure
The nasal step
There is a saying that a good perimetrist can smell a scotoma. And I would even say this is true for good perimetrists whether they examine with static or kinetic perimetry. But while there is not much influence to take in static perimetry besides choosing the appropriate program and strategy, the examination procedure in Goldmann kinetic is purely manual. Therefore different schemes exist and the one explained here is just an example. It is based on a quick assessment of the general conditions in each quadrant, a confirmation of the fixation stability and quality and a continuation of the examination that is strongly relating to the visual field and the subjects abilioties to cooperate with the perimetrist.
Especially in glaucoma, a sensitivity difference slightly above and below the nasal midline appears:
The guided vectors can be used in this situation.

37. Octopus Goldmann Kinetic
Examination procedure
Conclusion
Suggested procedure:
Blind spot with I4e, 2°/Sec.
Test reaction time
Outer periphery with III4e (sometimes III3e) 5°/Sec.
Additional isopters, eg. I3e, 5°/Sec.
I2e, 3 oder 5°/Sek.
Please refer to the Octopus 101
GKP manual or Octopus 900 SOP
(Standard Operating Procedure)
For the accuracy and readability of the result, the labelling of isopters and position identification of responses are esssential. Nonetheless there is an enormous examiner dependency in the recgnition and documentation of responses, in the speed of the stimulus movement and overall a certain danger of self-fulfilling expectations. Besides and maybe worst, sometimes even results are documented that have never really been tested as – after all – this examination is a drawing.

38. Reaction time compensation
Application example - 1

39. Reaction time compensation
Application example - 2
Blind spot size in 2 eyes, red isopter: not corrected
While reaction time may add some variability over all, the accuracy of the result is getting better. Red isopters show the areas of the blind spot before reaction time compensation, green lines after reaction time compensation. The intersubject variability decreases.

40. Reaction time compensation
Application example - 3
55 yrs, female, OD
Another example for compensation of reaction time is this examination. The 55year old female subject has a reaction time of approx ,5 seconds. When receiving “unlogical” results in the beginning of the test, the Orthoptist tested reaction time and activated compensation of reaction time for the continuing test. Now the responses given by the subject made perfect sense and the test could be completed.
Without compensation
With RT compensation: 2300ms (!)

41. Reaction time compensation
Advantages
Testing the real visual field
Receiving reaction time as additional information
Better reproducibility

42. Octopus Goldmann Kinetic
Automating tests
Use an existing test or draw a generic one
When drawing a generic test, click „Pause“ first

43. Octopus Goldmann Kinetic
Automating tests
Saving an existing test as standard test

44. Octopus Goldmann Kinetic
Automating tests
Selecting a test from the library

45. Octopus Goldmann Kinetic
Automating tests
Running the test automatically

46. Standardization of tests within the clinic
Automated testing
Advantages
Standardization of tests within the clinic
Combination of intial standard test and when needed individual continutation of the test
Simple to administer and delegate

47. Automated testing
Follow up button

48. Automated testing
Follow up button
The previous test performed on a patient is automatically repeated, no matter whether it was based on a standard test or was individual  Allows for progression analysis  Improves reliability
Simple to perform

49. Octopus Goldmann Kinetic
Features
Description
Goldmann like template
Age matched norms
Reaction time compensation
Individual test library
Follow up button
Implementation of „Complete examination“ and „Randomized sequence“ functions
Kinetic examination produces EMR response file

50. Octopus Goldmann Kinetic
Display and printout
Description
Turn on/off vectors
Zoom function
„What you see is what you get“ print function

51. Kinetic printout
Ausdrucksfunktionen

52. Kinetic Perimetry Application
Advanced visual field defects of any kind
Patients that require an interactive examination and cannot perform a purely automated test (when used in semi-automated or manual testing mode)
Neuro-Ophthalmic conditions
Peripheral visual field quantification and follow up for studying the medical safety of drugs

53. Static & kinetic perimetry
Application

54. Static & kinetic perimetry
Application
Example for the remainin local drop of sensitivity years after a Berlin edema

55. Glaucoma
Aulhorn III, S.M., f, 1944 OS

56. Glaucoma
Aulhorn IV, S.L., f, 1933 OS

57. Hemianopsia

58. Diplopia Double Vision
Octopus & Goldmann kinetic perimetry can be used with different response criteria
In this case, the patient shall respond whenever seeing two targets instead of one

59. Kinetic Training Learn, teach, repeat
Training software downloadable free of charge on
10 cases, partly with patient history
Full functionality
There maybe is no other eyetest as Goldmann kinetic perimetry that depends so much on the experience of the examiner. In order to allow exercising without a true subject and even without a perimeter, a training module has been developed that exactly simulates the different patient characteristics, the timing and behaviour of the instrument. This allows to get a realtime experience and truly helps to learn from basic to expert level.

60. Octopus & Goldmann Kinetic Perimetry
Thank you
Matthias Monhart
Octopus gives you a great outlook