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Understanding Visual Fields, Part I; Goldmann Perimetry

ournal of O
hthalmic Medical Technolo
Volume 2, Number 2
June 2006
Understanding Visual Fields, Part I; Goldmann Perimetry
Inci Dersu, MD, Michael N. Wiggins, MD, Anne Luther, RN, Richard Harper, MD, and
Joseph Chacko, MD
Why is this important?
Visual field testing is a common procedure in almost every eye practice. Whether you
are the person performing the visual field or working up a patient who just had a visual
field, it is helpful to have background knowledge of this common test. This article is the
first of a four-part series designed to review the basic types of fields, how to perform
them and the reasoning behind selecting one type of visual field over another.
What are we testing?
A normal patient can see 60 degrees nasally, 110 degrees temporally, 75 degrees
inferiorly and 60 degrees superiorly1. And you might think that all visual fields are
designed to measure the total peripheral vision. In fact, most commonly ordered visual
fields only test the central portion of a patient's field of vision. The amount of the field
tested depends on which test you perform. Only a few tests, such as the Goldmann visual
field (GVF), truly evaluate the whole visual field.
Types of Perimetry
Static, Kinetic, Manual or Automated?
There are two basic types of visual field tests commonly used in the clinic. Depending
on whether or not the stimulus moves, the test can be classified as static or kinetic.
Goldmann perimetry is a common example of kinetic perimetry. The Humphrey Field
Analyzer™ (Allergan-Humphrey, San Leandro, CA) is a common example of static
perimetry. In fact, both perimeters have the capability of doing both static and kinetic
tests, but in practice, they are used as described above.
Perimeters can also be classified as manual or automated, depending on whether
the stimulus is moved by hand as in the Goldmann, or if the stimulus location is changed
by a computer, as in the Humphrey visual field (HVF).
Terminology: Perimetry is the name of the technique whereas perimeter implies
to the machine i
Manual Kinetic Visual Fields (i.e. Goldmann Perimetry)
How to perform Goldmann Perimetry
Both the patient and perimetrist affect the accuracy of the GVF. The patient must be able
to understand the test, maintain fixation and respond appropriately. The perimetrist must
be experienced. It is important to calibrate the stimulus and the background illumination
at least once a week to maintain consistency of lighting.
The patient should be comfortably seated. Make all preparations for testing before the
patient is positioned in the machine. Lenses used to test the central 30 degrees are
determined by the patient’s distance correction and Goldmann’s add for age (Table 1).
Use the spherical equivalent whenever the cylinder is 1.00 diopter or less. Myopia,
aphakia, pseudophakia or dilation may affect the choice of lens power. People with high
myopia or aphakia may require a contact lens for accurate testing. Place the correct lenses
in the holder. Insert the perimeter paper and lock into place. Be sure that markings on the
paper are aligned with the notches of the frame. Explain the test to the patient. Assess the
patient’s ability to push the button on the buzzer in response to the stimuli. Some patients
find it easier to respond verbally. Patch the eye that is not being tested: the eye must be
completely covered. If there is significant dermatochalasis, tape the excess tissue. If
there is ptosis, taping may not elevate the lid sufficiently. In this case, an assistant may be
asked to hold the lid during testing of the superior visual field. Move the chin rest to the
correct side of the bowl. Help the patient move onto the chinrest and position the
forehead against the forehead strap (Figure 1). Emphasize the need to maintain this
position during testing. Some machines have a head strap that will help keep the patient
in the proper position throughout testing. Turn out the room lights.
Table 1. Adds for GVF perimetry
Age years Add for perimetry
30-40 +1.00
40-45 +1.50
45-50 +2.00
50-55 +2.50
55-60 +3.00
60+ +3.25
Figure 1. Positioning of examiner and patient for Goldmann Perimetry
The perimetrist should adjust his/her seat for comfort. Look at the patient’s eye through
the observer’s tube (Figure 2). If the patient’s eye is not centered in the observer’s tube,
adjust the vertical and horizontal position of the chinrest with the knobs located below the
paper. After this adjustment, ask the patient if he/she is comfortable. Choose the size and
intensity of the first target. The most common stimuli are I4e for peripheral and I2e for
central visual field. Stimuli of other sizes and intensities may be used to give greater
detail to the visual field. A GVF is performed by using the pantograph handle to move
the stimuli from the non-seeing area into a seeing area at about 3-5 degrees per second.
Start with the peripheral field without the correction. After the peripheral isopter is
determined, place the corrective lens into position and proceed with plotting the central
field. The blind spot is outlined with the smallest target that easily encompasses it. Static
checks to test for scotoma are done after the isopters are completely outlined. To avoid
patient fatigue, the test should not exceed 10 minutes per eye. Allow any patient showing
signs of fatigue to have rest times during the test.
It is important to evaluate the patient’s ability to do visual field testing. Retesting areas
will give you information about the consistency of the patient’s responses. Occasionally,
turn off the stimuli and stop testing for a few seconds: the patient should not respond
during this time. Watching the patient’s eye through the observation tube while moving
the pantograph handle, allows evaluation of fixation. If responses are inconsistent or
fixation is poor, reinstruct the patient.
After testing the first eye, allow the patient to sit back and rest while preparations are
made for testing the other eye. Look over the completed test to verify all quadrants have
been tested sufficiently.
Figure 2. Recording the results during Goldmann Perimetry
Interpreting a Goldmann Visual Field
The Goldmann Visual field tests the entire visual field, one eye at a time, by plotting
points along circles known as isopters (Figure 3). Each isopter should be color-coded to
the size and intensity of the stimulus used. The size and intensity of the stimulus can be
adjusted. The stimulus size varies between 0 toV, and the intensity varies between 1 and
4 for each 5 dB (decibel) change and further differs between a-e for smaller (1 dB)
changes (Table 2). For example, a III 2e stimulus is larger and brighter than a I 2d
stimulus, but not as large or as bright as a IV 3a stimulus.
Figure 3. A normal GVF. Note that a dimmer stimulus (I 2e) is used centrally and a
brighter stimulus (I 4e) is used peripherally. This GVF is shown with two isopters: one
in red and one in blue. The physiologic blind spot is also seen para-centrally as a filled-in
blue circle.
Table 2. Options for the stimulus
Size: 0, I, II, III, IV, V : 0 is the smallest, V is the largest
Intensity: 1, 2, 3, 4 : 1 is the dimmest, 4 is the brightest
Intensity: a, b, c, d, e : a is the dimmest, e is the brightest
Unlike defects on most automated visual fields (which show up as dark areas), most
defects on a GVF are changes in the isopter. If the circle has an indented area (see the
blue circle in Figure 4 below), this represents an area of the visual field where the
stimulus was not seen. Additionally, the distance between the isopters is important. If
the defect is mild, the isopter will look indented towards the center, but will remain about
the same distance away from the other isopter. However, when the defect is more severe,
Terminology: Decibels are a way of comparing the intensity of light to the
maximum possible light intensity the machine can produce. It does not have a
value that can be measured somewhere other than in the machine, like meters or
pounds. 10 dB means the light is 1/10th as bright as the brightest light possible,
20 dB means the light is 1/100th as bright (it is based on log units). So, the
higher the number of dB, the dimmer the stimulus. For example, a I 2e stimulus
is 5 dB more (or dimmer) than a I 3e stimulus1.
the isopters will be much closer together2. Dense central defects on GVF are generally
shaded in, similar to automated tests (Figure 5).
Advantages and Disadvantages er stimuli are used for testing the very center of vision
en, it is
dications to use a Goldmann Visual Field ated visual field. Some patients fall ated
. The full extent of the visual field needs to be tested. A GVF can be a reliable, of time.
. A visual field defect found on an automated visual field needs to be confirmed. In f
t l
During Goldmann perimetry, dimm
with the intensity increasing as more peripheral portions of the field are tested.
Some patients might prefer it because there is human interaction. By the same tok
very much examiner dependent1. It may not be reproducible by another examiner, and it
does not have the advantages of a computerized system for storage and comparison to
normative data. Additionally, kinetic perimetry may not be as sensitive as static
perimetry in detecting early glaucoma defects3. However, Goldmann visual fields
reveal scotomas that were missed between the testing points in static perimetry4. The
shape of the defects may also be more impressive in Goldmann perimetry1. With sever
vision loss (vision worse than 20/200), test-retest variability might be better in
comparison to automated static testing. In addition, it shows functional (non-or
defects on visual field testing better than automated testing.
1. The patient cannot reliably perform an autom
asleep or may become disinterested in participation if left unmonitored during autom
testing. Goldmann perimetry cannot be performed without an examiner, so constant
patient monitoring is present.
reproducible test for the full field and can usually be performed in a short amount
routine practice, the automated field is usually just repeated in these cases. However, i
the results must be confirmed on the same day as the original automated field and the
patient is tired, then a GVF may be appropriate. Additionally, a new visual field defec
found on automated testing that also manifests on GVF testing is more likely a true visua
field defect than an artifact of the test (Figure 4).
Figure 4. Side by side comparison of a GVF and a HVF. Note
the missing area (upper left portion) of the blue I 2e isopter on
the GVF corresponding to the black shaded area in the upper
left quadrant on the HVF. Also note that the lower left
quadrant of the HVF also shows a visual field defect, but the
Specific Uses of Goldmann Visual Fields
Low Vision
Goldmann visual field testing is preferred over automated visual field testing for low
vision patients with central scotomata for the following reasons: 1) fixation is easier to
monitor when a human perimetrist is performing the test since they can provide direction
and encouragement to the patient and 2) also due to difficulties with fixation, a human
perimetrist is better able to map the size and shape of the central scotoma. The size and
shape of the central scotoma can be helpful in guiding the patient and therapist during
eccentric viewing training in locating a preferred retinal locus. Other less common
indications would include patients with isolated peripheral islands of remaining visual
field and patients who are unable to provide reliable automated visual field responses.
Figure 5. Note the large central scotoma in this patient with low vision.
Goldmann visual fields (GVF) are essential to the practice of Neuro-Ophthalmology. In
fact, ophthalmic techs with training in GVFs are widely sought-after. First of all, the
GVF is used when patients are unable to perform a Humphrey visual field (HVF). This
may be due to fatigue, slower cognitive skills, low reliability, poor fixation, or decreased
vision. Secondly, the GVF is helpful when the visual defect is located or extends beyond
the central 30 degrees (peripheral visual field defect). Lastly, the GVF is extremely
useful in patients with functional visual loss. These patients have no organic basis for
their decreased vision. They run the gamut from malingerers (to feign for gain) to the
psychologically depressed (subconscious loss of vision). Certain visual field defects are
indicative of functional patients. These include spiraling isopters (Figure 6), crossing of
isopters, and severely constricted fields (Figure 7).
Figure 6. Spiraling of Isopters. Note both isopters constrict as the test progresses.
Figure 7. Constricted Visual Fields OU which improve to normal one month later
with reassurance that no organic lesion exists.
Goldmann visual field testing is an invaluable test to detect and follow the progression of
scotomas in a variety of ocular diseases, especially when performed by an experienced
tester. However, the ease and other advantages of using computerized systems has
relegated GVFs to mostly a second choice test. Although older, it still has value in our
clinics and should be understood by all ophthalmic personnel. Its newer sibling,
automated perimetry, will be visited in part II of our four part series on understanding
visual fields.
This work was supported in part by an unrestricted grant from Research to Prevent
Blindness and the Pat & Willard Walker Eye Research Center, Jones Eye Institute,
University of Arkansas for Medical Sciences (Little Rock, AR).
1. Alward, W. Glaucoma the requisites in Ophthalmology. Krachmer, J editor; Mosby,
St Louis; 2000; p57-61.
2. Anderson DR. Testing the Field of Vision. Mosby, St.Louis; 1982.
3. Katz J, Tielsch JM, Quigley HA, Sommer A. Automated perimetry detects visual field
loss before manual Goldmann perimetry. Ophthalmology 1995;102(1):21-6.
4. Choplin NT, Edwards RP.Visual Field Testing with the Humphrey Field.2nd ed. New
Jersey: SLACK;1999.
... The children have to report by pressing a button, whether they can see the target or not. The visual field of the child is then plotted [37]. In the broad H test, the children are asked to follow a target (a penlight) which is moved in an H pattern to the edge of the binocular field. ...
... Ophthalmological examinations were available in a subsample of 13 children. Three children had a visual field defect as measured using Goldmann visual field perimetry (2 hemianopsia, 1 quadranopsia; see Table 2), and 3 children had a deficit of eye motility [37]. Two of those three children had at least 1 abnormal result upon testing of visuospatial attention. ...
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Aim: This observational study aimed at assessing the prevalence of visuospatial attention deficits in children with unilateral spastic cerebral palsy (USCP), taking into consideration the affected hemibody and the localization of the brain lesion. Method: Seventy-five children with USCP were assessed with four visuospatial attention tests: star cancellation, Ogden figure copy, line bisection, and proprioceptive pointing. Results: A majority (64%) of children with USCP presented a deficit in at least one test compared to the reference values. The alterations observed in children with left or right USCP were related to egocentric or allocentric neglect, respectively. Children with cortico/subcortical lesion presented more often visuospatial attention deficits than children with periventricular lesion. Visuospatial attention deficits were not associated with brain lesion locations. Interpretation: Visuospatial attention deficits are prevalent in children with USCP and should be taken into account during their rehabilitation process. The present results shed new light on the interpretation of motor impairments in children with USCP as they may be influenced by the frequent presence of visuospatial deficits.
... Both automated static and manual kinetic perimetry adequately detect occipital lesions (Wong & Sharpe, 2000). However, manual kinetic perimetry provides enhanced information regarding location and extent of V1 damage (Alward, 2000;Choplin & Edwards, 1999;Dersu et al., 2006;Wong & Sharpe, 2000). ...
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Purpose: To retrospectively study the rate of visual field (VF) progression in patients with retinitis pigmentosa (RP) as it relates to different targets and inheritance patterns. Methods: A total of 275 kinetic VF tests were collected from 52 subjects with RP over a period of up to 29 years (mean, 12 years). The VF areas of Goldmann targets V4e, III4e, and I4e were calculated using Photoshop. Differences in the rate of VF loss among different targets and inheritance patterns were compared. Results: There was a significant interocular correlation in both visual acuity (VA) (R2 = 0.739, P < 0.001) and VF area (R2 = 0.815, P < 0.001). The annual rates of decline in VF area for V4e, III4e, and I4e targets were 7.5%, 10.7%, and 12.5%, respectively (all P < 0.001). All of the rates were significantly different from each other (P < 0.001). The mean rate of VF loss was 10.3% (P = 0.009) for autosomal recessive, 2.7% (P = 0.215) for autosomal dominant, and 7.2% (P = 0.009) for X-linked patterns of inheritance. However, the differences among them were not statistically significant (P > 0.05). Based on VF, survival analysis indicated that our patients failed the vision standard for driving and reached legal blindness at the median ages of 37 and 55 years, respectively. Conclusions: The rate of VF loss varies among targets in patients with RP. Fifty percent of patients are not qualified to drive by the age of 37 and become legally blind by the age of 55. These results can be useful for counseling patients with RP as to their potential rate of VF decline.
... Consistent with the Goldmann size III stimulus (Dersu, Wiggins, Luther, Harper, & Chacko, 2006), the test target was a small light disc with a diameter of 0.438. The luminance of the target varied between 31.5 and 950 asb, corresponding to sensitivity 25.0 to 10.2 dB, where dB ¼À10 3 log 10 (luminance, in asb/10,000). ...
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Measuring visual functions such as light and contrast sensitivity, visual acuity, reading speed, and crowding across retinal locations provides visual-field maps (VFMs) that are extremely valuable for detecting and managing eye diseases. Although mapping light sensitivity is a standard glaucoma test, the measurement is often noisy (Keltner et al., 2000). Mapping other visual functions is even more challenging. To improve the precision of light-sensitivity mapping and enable other VFM assessments, we developed a novel hybrid Bayesian adaptive testing framework, the qVFM method. The method combines a global module for preliminary assessment of the VFM's shape and a local module for assessing individual visual-field locations. This study validates the qVFM method in measuring light sensitivity across the visual field. In both simulation and psychophysics studies, we sampled 100 visual-field locations (60° × 60°) and compared the performance of qVFM with the qYN procedure (Lesmes et al., 2015) that measured light sensitivity at each location independently. In the simulations, a simulated observer was tested monocularly for 1,000 runs with 1,200 trials/run, to compare the accuracy and precision of the two methods. In the experiments, data were collected from 12 eyes (six left, six right) of six human subjects. Subjects were cued to report the presence or absence of a target stimulus, with the luminance and location of the target adaptively selected in each trial. Both simulations and a psychological experiment showed that the qVFM method can provide accurate, precise, and efficient mapping of light sensitivity. This method can be extended to map other visual functions, with potential clinical signals for monitoring vision loss, evaluating therapeutic interventions, and developing effective rehabilitation for low vision.
... Goldmann visual field perimetry is the preferred method to clinically assess visual fields in patients with low vision or complex scotomas. [43] Subjects with very low VA, (V01, V02 and V03) were unable to see more than hand movements and hence were unable to have their visual fields measured in the last five years. Despite this, each subject had a reported history of reducing peripheral vision and a clinical diagnosis of RP. (TIF) S1 Fig. Questionnaire form. ...
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... Although automated static perimetry has replaced a lot of indications for performing kinetic perimetry, its utilization is still relevant and an essential diagnostic tool for many different indications. In general, kinetic perimetry is used when the visual field defects are dense and large, when the shape of visual field defect is important in disease diagnosis and monitoring or when patients benefit from interaction with the examiner (Dersu et al. 2006). Kinetic perimetry can also be used to assess patients' fitness to drive. ...
Purpose To evaluate the clinical usefulness and reproducibility of (semi‐)automated kinetic perimetry of the Octopus 900 and Humphrey field analyzer 3 (HFA3) compared to Goldmann perimetry as reference technique. Methods A prospective interventional study of two study groups, divided into three subgroups. The first study group consisted of 28 patients, performing one visual field examination on each of the three devices. A second group of 30 patients performed four examinations, one on Goldmann and three on Octopus 900 with the following testing strategies: (1) with reaction time (RT) vector, no headphone; (2) without RT vector, no headphone; and (3) without RT vector, with headphone. Comparisons for V4e and I4e stimuli were made of the mean isopter radius (MIR) and of the distances of the isopter to the central visual axis in four directions. Statistical analysis was made with the R software version 3.2.2. Results For V4e stimuli, the mean isopter radius showed no statistic significant difference comparing Goldmann to HFA3 [p‐value = 0.144; confidence interval (CI) −0.152 to 0.019] and comparing Goldmann to Octopus 900 without RT vector, either with (p‐value = 0.347; CI −0.023 to 0.081) or without headphone (p‐value = 0.130; CI −0.011 to 0.095). Octopus 900 with RT vector produced a significantly larger MIR for V4e stimuli in comparison to Goldmann (p‐value < 0.001). I4e stimuli produced statistically significantly larger visual field areas when comparing HFA3 and Octopus 900 to Goldmann perimetry. Conclusion Humphrey field analyzer 3 and Octopus 900 without RT vector are promising successors of Goldmann perimetry.
People with multiple sclerosis (pwMS) report many different visual complaints, but not all of them are well understood. Decline in visual, visuoperceptual and cognitive functions do occur in pwMS, but it is unclear to what extend those help us understand visual complaints. The purpose of this cross-sectional study was to explore the relation between visual complaints and decline in visual, visuoperceptual and cognitive functions, to optimize care for pwMS. Visual, visuoperceptual and cognitive functions of 68 pwMS with visual complaints and 37 pwMS with no or minimal visual complaints were assessed. The frequency of functional decline was compared between the two groups and correlations were calculated between visual complaints and the assessed functions. Decline in several functions occurred more frequently in pwMS with visual complaints. Visual complaints may be an indication of declined visual or cognitive functioning. However, as most correlations were not significant or weak, we cannot infer that visual complaints are directly related to functions. The relationship may be indirect and more complex. Future research could focus on the overarching cognitive capacity that may contribute to visual complaints. Further research into these and other explanations for visual complaints could help us to provide appropriate care for pwMS.
Aim: To compare kinetic perimetry on the Humphrey 850 and Octopus 900 perimeters for assessment of visual fields, uniocular rotations and fields of binocular single vision. Methods: Prospective cross section study comparing Humphrey 850 kinetic perimetry to kinetic perimetry using the Octopus 900. Results were compared for both perimeters for the measurement of visual field boundaries, uniocular rotations and fields of binocular single vision in subjects with normal visual function, with comparisons of mean vector extremity values and duration of testing. A visual field boundary overlay was used to assess detection potential of Humphrey 850 kinetic perimetry using I4e and I2e targets in results of known abnormal visual fields. Results: Fifteen subjects (30 eyes) with normal parameters of visual function underwent dual perimetry assessment. Mean visual field boundaries and ocular rotation extremity values were similar for Humphrey and Octopus kinetic perimetry along horizontal meridians. Measurements for Humphrey perimetry were significantly smaller for superior and inferior visual field and rotations with ceiling effects at approximately 40 and 50 degrees, respectively. Use of visual field boundary overlays for 140 patient results showed high detection of the known abnormal visual field results by the Humphrey 850 perimeter (91.4% with I4e target; 95% with I2e target) but with notable exceptions for peripheral superior visual field defects. Conclusions: The Humphrey perimeter's aspheric bowl introduces a ceiling effect for measurements in the superior and inferior visual field at approximately 40 and 50 degrees respectively. This results in potential diagnostic accuracy issues when measuring uniocular rotations, fields of binocular single and visual field boundaries in conditions that specifically impair superior and/or inferior ocular motility (e.g., thyroid eye disease) or visual fields (e.g., chiasmal compression).
To determine if automated perimetry detects visual field defects before manual Goldmann perimetry. Subjects with ocular hypertension without field loss on detailed manual perimetry were followed prospectively with annual automated and manual perimetry. Subjects with field loss on manual perimetry were age-matched post hoc to subjects who did not have field loss. The automated fields 1 year before the development of field loss on manual perimetry were compared between the two groups. Subjects were recruited from ophthalmologists' offices, eye clinics, and a population-based glaucoma survey in the Baltimore area. Abnormal results detected on the Humphrey Field Analyzer were defined using the glaucoma hemifield test, mean defect, and corrected-pattern standard deviation. Forty subjects who had field loss during 8 years of follow-up were compared with 145 control subjects with ocular hypertension who did not have defects. Seventy-five percent of converters had abnormal results of the glaucoma hemifield test 1 year before field loss on manual perimetry, whereas 22% of controls had abnormal results of the glaucoma hemifield test (odds ratio, 13.4). The odds ratio of field loss developing on manual perimetry within 12 months was 3.3 for those with borderline results of the glaucoma hemifield test relative to the control subjects. The odds ratio was 6.0 for corrected-pattern standard deviation (P < 0.05) and 3.9 for mean deviation (P < 0.05). Those with field loss on manual perimetry were more likely to have had an abnormal automated field 1 year before conversion than those who did not convert. However, 22% of subjects in whom definitive field loss did not develop on manual perimetry during the study had abnormal automated fields at one visit and 15% had abnormal automated fields on two consecutive visits.
Visual Field Testing with the Humphrey Field.2 nd ed
  • Nt Choplin
  • Rp Edwards
Choplin NT, Edwards RP.Visual Field Testing with the Humphrey Field.2 nd ed. New Jersey: SLACK;1999.
Glaucoma the requisites in Ophthalmology. Krachmer
  • W Alward
Alward, W. Glaucoma the requisites in Ophthalmology. Krachmer, J editor;