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Clinical Decision Making I: Visual Field

Interpretation
30 Shirley Ann Hancock PhD, BSc (Hons), MCOptom

Visual field assessment provides a measure of the neural pathway integrity

11/07/08 CET

from eye to visual cortex. Certain patterns of visual field defect are associated
with damage to specific regions of this pathway. Inaccurate test results can
compromise interpretation leading to potentially serious consequences for
diagnosis and ultimately the management decisions for that patient.

Revision of the visual macula fibres nasal to the fovea decussate (cross-over) to the opposite
pathways (maculo-papilla bundle), follow a side of the brain tissue en route to each
The anatomy of the sensory visual direct course across the retinal surface occipital lobe. Axons from retinal
system is described here very briefly, to turn down through the ONH at its ganglion cells nasal to the fovea, which
and reference to a detailed text is temporal border. They form the core of carry information from the temporal
strongly recommended 1,2. the optic nerve with axons from the visual field, cross the midline to join
The optic nerve head (ONH) so superior retina uppermost and those axons from the temporal retinal
readily discerned by ophthalmoscopy from the inferior half of the retina, ganglion cells, that do not cross in the
is considered the reference location to beneath them. Those macula fibres chiasm. Together these form the optic
which features are related from an temporal to the fovea arch around the tracts. Once again the division of the
anatomical or structural perspective. maculo-papilla bundle to enter the fibres from each half of the retina is
However, from a functional supero-temporal and infero-temporal through the fovea as represented in the
perspective, when assessing the visual ONH boundaries. Fibres arising nasal field of view by the point of fixation.
fields, its projected representative, the to the optic disc travel radially directly The blind spot falls entirely within the
blind spot takes a minor role. Instead, to the nasal side of the ONH. The ONH temporal field.
the fovea and fixation with its forms the intraocular portion of the The fibres leaving the optic chiasm
significant representation at the cortical optic nerve. Beyond this region the 1.2 course posterio-laterally to synapse in
level becomes the key reference locus. million afferent nerve fibres travel a the lateral geniculate nucleus (LGN),
The inverted visual representation further 25-30mm intraorbitally, passing where they retain a well-defined
that is generated by the optical system via the optic foramen to the optic canal laminar organisation. The crossed
focussing light entering the eye, is in the orbital wall to emerge into the fibres terminate in layers 1,4 and 6
maintained throughout the visual intracranial section. The optic nerve whilst the uncrossed ipsilateral fibres
system. Lesions temporal to the fovea travel for another approximately 10mm synapse in layers 2, 3 and 5. The
give rise to nasal visual field defects to reach the chiasm.3 macula fibres occupy a proportionally
whilst those superior to the fovea or The term, ‘chiasm’ is derived from large area within this structure. The
involving superior-originating fibres at the Greek letter chi that describes the LGN is quite small and it is unusual for
any point along the pathway produce shape of the neural tissue at the region a lesion to involve the nucleus alone
inferior visual field loss. where the optic nerves from each eye without encroaching on the optic tract
The ganglion fibres originating from converge. It is about 4mm thick and on or radiations either side of it.
the innermost layer of the retina tend to average 10-12mm wide by 8mm in Upon leaving the LGN, the upper
group themselves by regions according length. At the chiasm approximately fibres of the optic radiations take a
to their origin relative to the fovea. The half of the nerve fibres from each eye relatively direct course backwards,

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spreading in a broad fan through the

parietal lobe to terminate in the
occipital visual cortex. The lower fibres
initially loop forward towards the
anterior pole of the temporal lobe to
form Meyers Loop, before turning back
to join the lower part of the optic
radiations at the occipital pole.
31
Guidance in choosing an
appropriate test

11/07/08 CET
strategy/program
To interpret visual field plots one needs
knowledge of the visual pathways. An
appreciation of the skill, or arguably
the art, employed supervising a visual
field test particularly under less than
favourable conditions should also be
expressed.
The human visual system is poor at
estimating absolute magnitude of light
intensity but remarkably good at
perceiving contrast. This facility is
evaluated when a visual field test is
performed. By measuring the
differential light sensitivity to a
stimulus against a standardised,
constantly illuminated background,
one can obtain an estimate of the
threshold for detection at a given
retinal location.
The choice of visual field test
depends on the degree of detail
required and the patients’ ability to co-
operate. One of the most valuable < Figure 1
techniques to master is confrontation Typical printout from Automated Static Threshold Perimetry
testing, particularly in suspected
neurological disease. Confrontation characteristic of parietal lobe lesions. interpolation of the visual field is
testing being both rapid and simple Testing the macula area with an Amsler introduced in the post-test processing.
should always precede any more Chart is useful for rapidly screening the Manual perimetry has been considered
detailed attempts with more central 20° of the visual field, despite superior to automated perimetry for
sophisticated automated static or sensitivity being relatively low. neurological fields, but recent studies
manual kinetic perimetry. For those Automated perimeters that include have found the Swedish Interactive
patients too poorly, whether mentally the Humphrey Visual field analysers Thresholding Algorithms (SITA) to be
or physically, this test can be most and Henson perimeters are less comparable 4,5.
informative. It can reveal the presence operator dependent than for the Static testing, whereby the stimuli
of a constricted field or altitudinal, manually operated Goldmann are presented at specific locations and
quadrant or hemifield defect (see perimeter. The tested locations are their brightness is varied are relatively
definitions later). standardised and provide a high level sensitive to shallow depressions of the
By employing simultaneous testing of quantitative data that allows visual field where there are flat almost
of opposite quadrants it is possible to statistical analysis and facilitates data equally sensitive areas. Kinetic testing
detect asymmetric subtle relative storage and transfer of information. is more useful in regions whose
visual field defects or ‘extinction’. The They can be tedious to perform sensitivity sharply changes between
latter phenomenon occurs when a irrespective of age, even with the adjacent areas. Goldmann perimetry
target is missed in an affected benefit of the newer interactive employs primarily a kinetic technique
hemifield only when both hemifield algorithms. There are limited choices to plot boundaries of isopters (points
are tested simultaneously and is to test speeds and a degree of joined together by a drawn line with
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By the subjective nature of a visual

field test, the results can be profoundly
affected should the test operator take
insufficient care. It is they who generally
provide initial instruction and a brief
explanation of why the test is being
performed and its relevance to the
patients’ management. Although the
32 patient may claim to have done a similar
test previously, one should repeat the
instructions and consider running a
11/07/08 CET

demonstration programme to familiarise

each person with the test. This allows
for retinal adaptation and overcomes
some of the apprehension that many
experience when faced with the
demands of formal perimetry.
Unless functional vision for driving or
mobility purposes is being evaluated,
the non-test eye should be appropriately
occluded. Fixation should be directed to
a single point to ensure steady fixation,
< Figure 2 with the patient alert and mentally
Schematic of visual pathway. Letters A-J correspond to pairs of VF plots in Figure 3 competent.
The blind spot, temporal to fixation,
equal levels of estimated sensitivity) however some exceptions that involve represents the projection into visual
and scotomas (depressed areas of only the peripheral retinal fibres, the space of the ONH, nasal to the fovea,
sensitivity) by moving a visual temporal crescent represented region of where the ganglion cell axons exit at the
stimulus from a non-seeing to a seeing the occipital lobe or associated with a back of the eye. It produces a small,
region. Additional static testing is then stato-kinetic dissociation. Peripheral physiological, absolute scotoma. If
used to verify the regions within a visual field programmes should be fixation is not maintained the blind spot
given isopter and as catch trials to undertaken if doubt exists over the is less likely to be plottable and the
reveal false positive, negative and results of a central VF programme credibility of the visual field test
fixation losses. when neurological disease is evidence derived from the rest of the
Supra-threshold testing until the suspected. procedure is brought into doubt.
newer thresholding algorithms were Should a group of 2 or 3 points (a A comfortable, correctly aligned set-
developed was considered the least ‘cluster’) at the edge of a 24° visual up for the patient should be established
time consuming. The stimuli field examination be abnormal then and maintained. Gentle encouragement
brightness selected is chosen such that one should consider repeat testing and at appropriate intervals may be required
subtle shallow defects are unlikely to include a peripheral plot. Similarly, if to optimise a relaxed yet attentive
be revealed. By using multiple fixation and visual acuity are attitude. During the course of the test,
stimulus patterns the test duration can reasonable good, but visual field the operator should seek to minimise
be further reduced. Threshold testing, abnormalities are extensive and fixation losses, by monitoring eye and
on the other hand, uses single stimuli threaten the 5-10° region, then head movements visually, alerting
testing and an estimation of the selecting a specific macula programme patients to poor stability and replotting
threshold based on ‘frequency-of- with greater sampling of locations close the blind spot position if incorrectly
seeing’ characteristics. Greater detail of to fixation would reveal the risks to identified by the subroutines that most
defect depth and extent is possible vision. The results are then interpreted modern automated perimeters use. Brief
when using a thresholding system. both qualitatively for patterns of visual rests can be incorporated within and
The choice of programme for visual field abnormality and quantitatively in between the test of each eye and the
field assessment is dependent on the terms of depth or degree of damage. patient should be encouraged to blink
suspected lesion. Generally, central naturally during the test sequence,
visual field programmes are considered Determination of test without the perceived fear that stimuli
adequate to reveal the majority of reliability may be missed to the detriment of their
visual field defects that one is likely to Sources of error can be broadly test result. The test may need to be
encounter arising from intracranial categorised into those arising during restarted, repeated or even aborted if the
lesions, including those at the optic the test period and those introduced operator judges the results being
chiasm or optic tract. There are in the subsequent analysis and generated to be significantly unreliable.
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The printout provides clues to the checked to establish their authenticity. had obscured the view of the default
reliability of the test results. Comments The personal data (Figure 1, A) fixation target. A refractive error
made by the patient or by the operator should be scanned to confirm the correction should have been chosen
documented at the time of the test are patient’s full name, their date of birth appropriate to the test distance to
invaluable when considering the true (including correctly stated year), how compensate for significant ametropia,
value of the information generated. recent the test. If the test duration including astigmatism and presbyopia.
Patients may admit to having seen stated was longer than expected for that The operator should always verify that
repeated stimuli to which they had not test strategy, it is worth verifying that the lenses chosen are single vision, full
responded. They may have been appropriate rest periods were given aperture, correctly powered and 33
distracted mentally by anxiety, their ill and the eye to which it relates. aligned, and do not ‘steam-up’ or get
health, or extraneous noises. The test Significant alterations to pupil size touched during the test. If contact

11/07/08 CET
duration reported on the printout does can lead to diffuse visual field changes, lenses were worn for the test, one needs
not account exclusive for rest periods, so pupil diameter should have been to ensure that suitable ‘over’ correction
that may, by necessity, have been recorded if the patient was known to be was chosen. Presbyopia corrective
frequent albeit brief. using miotic or mydriatic eyedrops. An contact lens designs are becoming more
Upon receiving the completed test alternative fixation target may have common. Inappropriately corrected
results, several points need to be been chosen if severe foveal damage refractive error can produce an
enlarged blind spot, diffuse field
depression and a more negative Mean
Deviation index.
Modern perimeters generally provide
some form of reliability indices (Fig.1,
B). These commonly include a measure
of fixation losses, false positive and
false negative responses. High fixation
losses suggest poor eye or head
fixation. Other causes include
inadequate occlusion of non-tested eye,
poor BS localisation, and poor
response button control. Whether the
index is a true representation of
fixation stability can be corroborated
by comments documented by the test
operator from their direct visual
observation at the time of the test. If an
automated fixation monitor has been
disabled, ‘zero fixation losses’ may not
necessarily represent excellent
fixation. False positive responses are
generally associated with anticipation
(‘trigger happy’) which can lead to a
more positive Mean Deviation index
and high Pattern Deviation values.
False negative errors can be attributed
to fatigue (health related or disturbed
sleep patterns), but are also known to
be present in patients with early onset
of visual loss, developing a relative
scotoma and demonstrating varying
visual response, or who already have
visual field defects that are progressing.
The time between testing for each eye
should be noted. Adequate but not
excessive rest should have been
provided and the previously occluded
eye given sufficient time to re-adapt to
< Figure 3 the background illumination. This can
Schematic paired sets of visual field plots for selected pathway locations be particularly pertinent if delayed
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34 Is VFD bitemporal?

Recheck
11/07/08 CET

1. Other eye for subtle

incongruous homonymous VFB
2. Poor px co-operation
3. Does this correlate with
fundoscopy?

Bilateral
Sectoranopia ON disease
Is VFD binasal?
or Disc
Drusen?
Inferior
Temporal lobe chiasm
optic radiations
Ischaemic
Glaucoma?
Parietal lobe optic neuropathy?
optic radiations

Inferior Altitudinal Possible causes: Possible causes:

Bilateral Diabetic PRP Bilateral ARMD Check ophthalmoscopy
Hemianopic Bilateral RP Bilateral Glaucoma
Bilateral retinoschisis Bilateral Choroiditis

Any postchiasmal lesion

< Figure 4
Visual Field Defect (VFD) Decision Tree

retinal adaptation is likely to be a factor boundary. It is good practice that each the test sequence. The threshold values
for example, in those with rod/cone of the isopters is annotated, in addition are a function of the instrument
dystrophies. to colour codes that indicate the dynamic range of contrast between
Goldmann visual field plots, stimuli characteristics from which they stimuli and the background
similarly should include the patient were derived. Subsequent evaluation illuminance. Small defects can be
name, date of birth, date of test, of the raw threshold values (Fig. 1, D) missed should they lie between the test
selected eye, refractive correction used in an automated perimetric printout, locations.
and the stimuli characteristics their associated age-corrected (Fig. 1, The Total Deviation grid (Fig. 1, E)
employed. It is assumed that the E), pattern corrected (Fig. 1, F) and provides pointwise age-corrected
instrument has been adequately probability-derived plots (Fig. 1, G) numerical values of the estimated
maintained and is calibrated regularly. depends upon the overall impression threshold. Comparisons across the
Generally the blind spot position/size of reliability that is given. horizontal and vertical meridia can alert
and at least three isopters are Grayscale plots (Fig. 1, C), despite one to potential abnormalities. The
presented, having been selected to their immediacy of visual field Pattern Deviation (Fig. 1, F) filters out
demonstrate the location, depth and representation can be misleading. They the presumed diffuse sensitivity
extent of any significant variation in have a limited palette of gray scale tone depression to highlight potential
the visual field. As with contour lines and regions between test locations regions of focal depressed function.
on an Ordinance Survey map, the undergo interpolation. The numeric These are statistically analysed to
closeness of the isopters to each other grid provides an estimate of patient generate the probability plots (Fig. 1, G)
indicates the rate of change in visual sensitivity in terms of decibel as to the likelihood of the estimated
sensitivity and the gradient of a values at locations determined during values indicative of normal function.
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suggestive of ‘compression’. affected eye (not dealt with in this

Identification of the likely Associated symptoms can assist in article). The pupil on the abnormal side
location of a suspected localisation though not wholly specific. appears to paradoxically dilate in
visual pathway lesion They can include ocular or orbital pain response to a light stimulus. An RAPD
One of the primary tasks is to determine (as in retrobulbar ON), diplopia, becomes more apparent when the
whether the lesion is intraocular hemiparesis, headaches, and in ambient lighting is dimmed. It can be
(IO) or intracranial (IC) 6. The IO lesion extreme cases variable levels of detected in the presence of a total 3rd
needs ophthalmological investigation consciousness. nerve palsy, as only one active pupil is
whereas the IC lesion needs neurological The ophthalmological or neuro- necessary to detect an RAPD. Bilateral 35
investigation. An inappropriate referral ophthalmological examination, is optic neuropathies (if equally
can cause delay in management by directed towards detecting, quantifying impaired) may show no relative

11/07/08 CET
several weeks or even months. If a and localising the region of vision loss. differences between the two pupil
patient describes a visual loss as being Any visual field test should be responses and an RAPD may not be
‘missing’ it suggests a ‘Negative’ scotoma interpreted in context with the other detectable.
that implies a neurological disease, results arising from a full examination. Careful direct monocular and
whereas a smear, smudge, cloud or veil This should include a measure of binocular slit lamp ophthamoscopy,
is classified as a ‘Positive’ scotoma and visual acuity, both best-corrected and preferably through dilated pupils,
implies a retinal disease or media pinhole vision at distance and near should establish whether a VFD arises
opacity. (line and single letter) and an wholly or partially from a retinal or
Knowledge of the visual pathway evaluation of the pupillary responses. anterior segment component. Optic
anatomy is required to differentiate The aim is to detect a relative afferent atrophy, if present, indicates damage to
between specific VF patterns. One pupillary defect (RAPD), which is the retinal ganglion cell, its cell body, or
should always check the VF from the characteristic of impaired optic nerve axon up to its synapse at the LGN. It
‘uninvolved’ eye for subtle defects even conduction. The presence of an RAPD can take 4-6 weeks from the time of
when symptoms are unilateral (such as is an extremely reliable and sensitive damage until it becomes apparent. The
in the case of a temporal defect in indicator of asymmetric optic nerve resultant atrophy can be diffuse or
junctional scotoma that could arise from dysfunction. It is likely to accompany segmental. Acute retrobulbar ON is not
a chiasmal compressive lesion). (See any substantial lesion that decreases normally associated with a swollen
figures 2 and 3). ganglion cell output to the optic nerve, optic disc. Atrophy, though not
The key points to consider for each for example severe age-related macular diagnostic in itself, demands
aspect, pertaining to the relevant degeneration, acute retrobulbar ON or immediate referral for thorough
ophthalmic and systemic factors, are a retinal detachment. It is derived from a investigation as to its cause. A VA of
careful and thorough history, the disparity between the direct and 6/6 or better does not exclude the
reported symptoms and identified signs, consensual light responses in an possibility of significant VF loss. Optic
and any visual field results.
The principal points of history taking
in cases of impaired vision are, the type
of involvement, whether unilateral or
bilateral, the time course of vision
dysfunction/disturbance and any
associated symptoms.
The possible cause of visual field loss
implied by the speed of onset can only
be inferred according to how soon the
patient becomes aware of loss. In terms
of the presumed time course in which
the condition has developed, sudden
onset (within minutes) usually indicates
an ischaemic event (e.g. occlusion of
retinal vessels from emboli), whilst rapid
onset (over hours) is also characteristic
of ischaemic event, but at the level of the
optic nerve. Moderately rapid (days to
weeks) is likely to be ischaemia-related,
but can also be linked to inflammation.
Gradual progression over months are
found in lesions of toxic origin, whilst < Figure 5a and 5b
slower progression of months to years is Set of Humphrey perimeter visual field printouts for MCQ number 8
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defined boundaries, whilst the

disorganised behaviour of tumour tissue
can involve more diverse regions.
Altitudinal defects respect the
horizontal meridian, involving either
pair of superior or inferior quadrants
(Figure 3 A). They are typical of
ischaemic optic neuropathies or a hemi-
retinal vascular occlusion, though they
36 can very rarely be due to bilateral
symmetrical lesions of the visual cortex.
Hemianopia describes a defect
11/07/08 CET

involving the complete right or left half

of the visual field. Quadrantanopic
defects predominantly involve one of the
four quadrants. ‘Heteronymous’
hemianopia refers to opposite halves for
each eye as in bitemporal hemianopia.
‘Homonymous’ defects affect the same
side for each eye, characteristic of
< Figure 6a and 6b retrochiasmal lesions. A complete
Set of Humphrey perimeter visual field printouts for MCQ number 9 homonymous hemianopia is non-
localising. The entire hemifield being
disc oedema results from impaired depressed sensitivity either relative involved confounds attempts to
axoplasmic transport that includes (dependent on the perimeter used) or differentiate between the likely
raised intracranial pressure, ischaemia, absolute (to any level of stimulus), retrochiasmal location that a visual
or inflammation. It is characterised by an surrounded by normal sensitivity. When pathway lesion has occupied.
elevated ONH, indistinct disc borders, the scotoma involves fixation, as often Homonymous visual field loss can be
venous and capillary dilation and found with age-related maculopathy, it is perceived by the patient as monocular
tortuosity, sometimes accompanied by termed ‘central’. If it also involves the loss to the eye of the affected hemifield
peripapillary haemorhages and maculopapillae bundle as found in toxic until examined.
exudates. Bilateral optic disc swelling optic neuropathies, or congenital optic A centrocaecal scotoma in one eye
needs urgent referral to a neuro- disc pits associated with central serous accompanied by a superior temporal
ophthalmologist opinion as MRI detachments, a centrocaecal scotoma can quadrantanopia in the other eye, termed
scanning may need to be arranged, even develop. A paracentral scotoma adjacent a ‘junctional’ scotoma, is suggestive of a
in the absence of vision disturbance. to, but not involving, fixation is typical prechiasmal lesion close to where the
Beware of the ‘silent’ neuro- of early glaucoma. Arcuate patterns that optic nerve meets the chiasm (Figure 3
ophthalmic patient presenting with can extend to the nasal boundary where C).
blurred vision (with or without reports a nasal step due to the asymmetry of By far the most common cause of
of loss of field). Confrontation field- sensitivity across the horizontal chiasmal disorders is compression by a
testing and RAPD evaluation (before meridian, often arise from glaucomatous tumour in the region of the pituitary
dilated fundoscopy) should always be visual field progression are associated gland, but rare non-compressive causes
performed, and if either are abnormal or with damage to the retinal nerve fibre including infection, inflammation, and
the degree of vision loss is inconsistent bundles at the optic disc poles. They can ischaemia and toxicity are encountered.
with the ocular examination, formal also be associated with ischaemic optic About 10mm directly below the chiasm
perimetric testing is required. neuropathy or congenital disc drusen. lies the sella turcica, a depression in the
The normal VF extends approximately Congruency describes the similarity in sphenoid bone that supports the
100 temporally, 60 nasally, 60 superiorly the shape of visual field loss or pituitary gland. Significant enlargement,
and 75 inferiorly from fixation in each conversely the visual field preservation with suprasellar extension of pituitary
eye7. Unilateral loss almost invariably between each eye. Generally, the greater tissue, is therefore necessary before it is
indicates an intraorbital lesion or one the similarity or congruency, the more likely to be associated with any field
anterior to the chiasm on the affected posteriorly located the lesion. Both defects. Suprasellar masses infrequently
side. Bilateral loss, can be indicative of anatomical and psychophysical cause raised intracranial pressure and
bilateral retinal or optic nerve origin, variability, however, confounds its optic atrophy occurs late in chiasmal
chiasmal or retrochiasmal location. diagnostic value. The degree of lesions. The extent of the defect does not
There are several terms that are used to congruency is not only dependent on the always correlate with the magnitude of
describe the type of defect that may be visual field region involved but also the the tumour since the damage to the fibres
encountered with perimetry. causative agent. An infarct to a cerebral can be both due to direct and indirect
Scotomas represent a focal area of vessel is generally associated with well- interference.
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Chiasmal Lesions, whether arising hemianopia, a congruous sectoral interfering with the superior optic
from the pituitary gland itself or the hemianopia that crosses the horizontal radiations (Figure 3 G). Parietal lesions
surrounding tissue, are rarely meridian and sparing of this sector but typically present with additional
accompanied by the classic, complete damage to the upper and lower sections. neurological deficits that confound
bitemporal field loss (Figure 3 D). They The latter two patterns result from formal perimetry and may only be
more commonly present with an optic occlusion of the lateral choroidal artery inferred from confrontation testing.
neuropathy and a varied pattern of field or ischaemia of the anterior choroidal Quadrant VFD that respects both the
defect, in one or both eyes, due to artery, a branch of the internal carotid, horizontal and vertical meridian is likely
compression of more than one structure. respectively (Figure 3 F & E). to be located along the calcarine fissure
They tend to fall into four basic groups; Partial homonymous hemianopias can at the cortex. 37
from above, from beneath, from the be categorised in terms of their degree of Lesions that occur at the Occipital
antero-lateral or postero-lateral direction congruity, whether predominantly in the Primary Visual Cortex potentially retain

11/07/08 CET
depending on the direction the lesion superior or inferior field or whether good visual acuity, particularly with
impinges on the chiasm. Chiasmal accompanied by macular sparing. distance vision but may have more
lesions can produce an RAPD though ‘Macular sparing’, whereby the difficulty with near vision if the text is
they tend to be more subtle than those hemifield defect includes preserved large or enlarged. Generally the lesion is
arising from a lesion of the optic nerve. central 3-5 vision, suggests a posterior not associated with optic atrophy unless
Anatomical variation in chiasm cerebral artery stroke with middle associated with raised intracranial
location and pathological variation in cerebral artery support, akin to the role pressure. The pupil reactions are
tumour growth pattern leads to diversity of a cilio-retinal artery in maintaining typically normal. The visual field defects
in the visual field defect presentation vision in central retinal artery occlusion. are highly congruous. There may be
and confounds precise interpretation. It is diagnostic of an occipital lobe additional neurological disturbances
Bitemporal hemianopias may be lesion, being rarely encountered with including hallucinations, alexia and loss
confined to the central visual fields lesions anterior to the visual cortex of colour perception.
particularly in lesions compressing the (Figure 3 J). A homonymous hemianopia Rarely, if a lesion should damage the
posterior portion of the chiasm. A that does not spare the fovea, causing tip of one occipital lobe, the patient may
bitemporal hemianopia which respects ‘Macular splitting’ has less localising complain of reading difficulties (despite
the vertical meridian that is value. no apparent macular abnormality) and
predominantly superior strongly suggest A predominantly superior Amsler grid testing or a central 10-2
compression from beneath, for example homonymous quadrantanopic field threshold programme with Humphrey
a pituitary adenoma whilst one biased defect (‘pie-in-the-sky’) may be due to a automated perimetry may reveal a small
inferiorly suggests a craniopharyngioma, temporal lobe lesion that impinges on homonymous paracentral scotoma
exerting force from above. These latter, the inferior bundle of nerve fibres that (Figure 3 l). The causes are primarily
slow growing tumours, occur in all age form the optic radiations (Figure 3 H). vascular, with occlusion along the
groups, but particularly children. An inferior defect (pie-on-the-floor) can posterior cerebral artery, or ischaemia
Binasal visual field loss is much more arise from a parietal lobe lesion caused by a cardiac embolus,
likely to be caused by optic nerve
damage, such as glaucoma since the
temporal retinal fibres do not merge and
are likely to only be simultaneously
involved if there is bilateral eye lesions.
Retrochiasmal Lesions (affecting the
optic tract, lateral geniculate body, optic
radiation) cause a partial or complete
homonymous hemianopia. Pure optic
tract or LGN lesions are rare. They can be
distinguished from lesions of the optic
tract by the absence of an RAPD. The
most common cause is cerebrovascular
disease, and although brain tissue
malignancy, inflammation, infection or
arteriovenous malformations are rare,
neuroimaging is necessary to exclude
these possibilities in all patients with
homonymous visual field defects.
Three types of VFD have been
attributed to LGN lesions, and each can
be accompanied by optic atrophy 8, 9, 10. < Figure 7a and 7b
An incongruous homonymous Set of Humphrey perimeter visual field printouts for MCQ number 10
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characteristic of a malingering cause.

The more common causes are:
• End stage glaucoma that is associated
with extensive optic disc cupping
• Retinitis Pigmentosa, accompanied by
retinal pigment clumping, disc pallor
and attenuation of the retinal arteries
• Extensive panretinal photocoagulation
in proliferative diabetic retinopathy
38 • Chronic Pailloedema with swollen or
pale optic discs
• Chorioretinitis with widespread
11/07/08 CET

retinal pigment disturbance or

functional loss
• Bilateral occipital lobe infarcts with
macular sparing supported by the
relevant history, neurological condition
and neuroimaging
• Functional loss due to hysteria or
malingering.

Selection of salient
observations to support
referral decision
Each referral should include the date,
full name of referring optometrist, their
practice address and contact telephone
number and the patients’ GP details in
block capital letters. The full details of
the patient, including their date of birth,
NHS number (if known) and a contact
telephone number should be provided.
The referral should be supported by a
salient history, to include the prime
complaint, its duration, whether
constant, intermittent, progressive or
stationary and the time of onset.
A list of current medication may also
prove useful (if known). If additional
neurological signs are observed, that
could include any or all of the following;
headaches, nausea/vomiting, loss or
impaired consciousness, unsteady gait,
speech or hearing impairment,
hemiparesis; then they need stating.
Test results should included a
measure of the current visual acuity and
< Figure 8a and 8b previous visual acuity (if known),
Set of Goldmann perimeter visual field printouts for MCQ number 11 indications as to the presence or absence
of RAPD, and a summary of the
vertebrobasilar occlusive disease, a tunnel vision field defect11 (Figure 3 B). ophthalmoscopic findings. If formal
arteriovenous malformations or in some One should differentiate between the perimetry or merely confrontation has
cases following cervical manipulations ‘true’ funnel type of constricted visual been undertaken, the type of visual field
that injure the vertebral arteries. Other field loss where the breadth of the defect defect, its repeatability and reliability
causes are primary and secondary changes with the distance at which the should be shown. The reason for the
tumours or trauma. test is performed and the tunnel vision referral, a provisional diagnosis and an
Arguably, some of the most difficult that remains the same angular subtense indication of its urgency, should be
cases to diagnose are those that produce for different test distances, that is clearly stated. (Figure 4).
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hemianopia needs urgent same day Heartlands Hospital with special interests
referral as the sooner the cause is in ophthalmic imaging and perimetry.
identified the greater the chance of any
visual recovery. References
It is not acceptable to send a patient to 1. Harrington DO, Drake MV (1990) The
an acute referral centre without an Visual Fields. Text and Atlas of Clinical
arranged appointment. Should a patient Perimetry.The C.V Mosby Company, St.
present with a condition that warrants an Louis, USA
emergency referral the centre to which the 2. Rowe F (2006) Visual Fields via the
referral is directed should be informed Visual Pathway. Blackwell Publishing 39
and appropriate advice or guidance Ltd.
sought. Suspected serious, purely 3. Kanski J (2003) Clinical

11/07/08 CET
intraocular conditions require same day ophthalmology: A Systematic Approach,
referral to an eye casualty unit, 5th edition. London, Butterworth-
ophthalmic outpatient clinic or an Heinemann.
Accident and Emergency Unit, dependent 4. Szamdry G, Biousse V, Newman NJ
on the local services available. Suspected (2202) Can Swedish Interactive
serious intracranial conditions with or Thresholding Algorithm Fast preimetry
without an intraocular component require be used as an alternative to Goldmann
referral to an Accident and Emergency perimetry in neuro-ophthalmic practice?
Unit. This is for guidance only as there Archives of ophthalmology 120: 1162-
may be guidelines, in place, according to 1173
the local arrangements. 5. Wall M, Punke SG, Stickney TL,
Brito CF, Witbrow KR, Kardon RH (2001)
S.U.P.E.R Summary Points SITA Standard in optic neuropathies and
hemianopias: A comparison with Full
(adapted from Pane, Burdon Threshold testing. Investigative
and Miller ) 12

Ophthalmology & Visual Science 42:

Suspect the possibility of a serious 528-537
intraorbital/cranial disease when a 6. Farris B K (1991) The Basics of
patient presents with a vision or eye Neuro-Ophthalmology. Mosby Year Book
complaint. 7. Douglas RA (1999) Automated
Understand and use the knowledge of the Static Perimetry (second edition) Mosby
visual pathway to formulate a systematic International Limited.
series of questions and investigations. 8. Rosen ES, Eustace P, Thompson
Perform a thorough and careful HS, Cumming HJK (1998) Neuro-
examination including a full history, Ophthalmology. Mosby International
ocular examination, confrontation test, Limited.
RAPD evaluation and formal perimetry. 9. Martin TJ, Corbet JJ (2000)
Evaluate the visual field results for Neuro-ophthalmology: The Requisites
< Figure 9a and 9b reliability and correlate with other in Ophthalmology Mosby International
Set of Humphrey perimeter visual field evidence for unilaterality or bilaterality. Limited.
printouts for MCQ number 12 Refer to a neuro-ophthalmologist 10. Walsh T J (1997) Neuro-
with appropriate urgency if the Ophthalmology Clinical Signs and
Recommendations for examination leads one to suspect a non- Symptoms. 4th Edition. Williams
ocular cause for a visual disturbance. and Wilkins.
referral prioritisation 11. Kline LB, Arnold AC,
There is a wide range of causes of Acknowledgements Eggenberger E, Forozan R, Golnik
binocular visual field defects. Some are Thanks for invaluable assistance with KC, Rizzo III JF, Shaw HE (2007)
sight and life threatening and it is not this article to Mike Burdon, Neuro- Basic & Clinical Science Course:
easy to differentiate from those that are ophthalmologist at Selly Oak Hospital, Neuro-Ophthalmology Section 5 2007-
not, without further investigations, such Birmingham and Dr Leon Davies, Aston 2008. American Academy of
as neuro-imaging. In general terms, all University, Birmingham. Ophthalmology.
those suspected of having a neurological 12. Pane A, Burdon M A and
feature need urgent investigation. A About the author Miller N R (2006) The Neuro-
young patient, particularly if Shirley Ann Hancock PhD, BSc (Hons), Ophthalmology Survival Guide. Mosby
symptomatic, needs a more urgent MCOptom, is a Principal Optometrist Elsevier Limited.
referral than an elderly asymptomatic based at the Heart of England NHS http://www.academy.org.uk/tutorials/
patient. A suspected bitemporal Foundation Trust, Birmingham pathway.htm
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Module questions Course code: c-8367

Please note, there is only one correct answer. Enter online or by form provided
An answer return form is included in this issue. It should be completed and returned to CET initiatives (c-8367)
OT, Ten Alps plc, 9 Savoy Street, London WC2E 7HR by August 13 2008.
1. Which of these statements is true? 7. Which of these statements about post-chiasmal lesions is true?
radiations
(a) (Figureemploys
Goldmann perimetry 3 G). both aParietal automated
kinetic and static technique. perimetry mayreactions
(a) Pupil reveal are a
normal Extensive
in lesions of panretinal
the LGN. photocoagulation
lesions typically
(b) In automated present
perimetry the backgroundwith illuminationsmall homonymous
is varied according paracentral
(b) A macula in proliferative
splitting homonymous diabetic
hemianopia indicates retinopathy
an occipital
to the testing programme. lobe lesion.
additional neurological deficits that scotoma (Figure 3 l). The causes are Chronic Pailloedema with swollen or
(c) Kinetic perimetry is more reproducible than static perimetry. (c) A contralateral, homonymous, inferior quadrantanopia arises from
40 confound
(d) End stage formal perimetry
glaucomatous and
visual field lossmay
can only primarily
be monitored byvascular, with damageocclusion pale
to the inferior fibres optic
of the discs Chorioretinitis with
optic radiations.
only Goldmann
be inferred from
visual field testingconfrontation along the posterior (d) cerebral
Lesions artery, or optic
of the anterior widespread retinal than those
radiations are more congruous pigment
testing. Quadrant VFD that respects ischaemia caused by involving
a the posterior radiations.
cardiac disturbance or functional loss. Bilateral
11/07/08 CET

2. In non-arteritic anterior ischaemic optic neuropathy, which of these

both statements
the horizontal
is true? and vertical embolus, vertebrobasilar 8. At whatocclusive
level of the visualoccipital
pathway does lobe infarcts
the lesion with
that gives rise to macular
the
meridian is likely
(a) It typically causes an toinferior
be located
altitudinalalong
field defect.disease, arteriovenous pair malformations sparingin Figure
of visual field plots illustrated supported by likely
5a and b most the lie? relevant
the Visual loss usually
(b) calcarine develops
fissure at over
the2-3cortex.
days. or in some cases (a) Retina or Optic
following nerve
cervical history, neurological condition and
(c) Visual acuity improves with time. (b) Chiasm or Optic Tract
Lesions that occur at the Occipital
(d) It usually causes a centrocaecal type field defect.
manipulations that injure the vertebral
(c) LGN or Optic radiations
neuroimaging Functional loss due to
Primary Visual Cortex potentially arteries. Other causes (d) are primary
Visual Cortex and hysteria or malingering.
3. Which
retain good of these
visual statements
acuity, is true? Acute retrobulbar
particularly ON is usually tumours
secondary or trauma.
with associated
distance with:vision but may have Arguably, some of 9.theAtmost
(a) An altitudinal field defect.
what level Selection of salient
of the visual pathway does the lesion that gives rise to this
difficult
pair of visual field plots illustrated in Figure 6a and b most likely lie?
more difficulty
(b) Normal with near vision if the cases to diagnose(a) are
pupil reactions. Retinathose
or Optic that
nerve observations to support
text
(c) is large or
A swollen opticenlarged.
disc. Generally the produce a tunnel vision field or
(b) Chiasm defect 11
Optic Tract referral decision
(d) Painison not
lesion eye movements.
associated with optic (Figure 3 B). One should (c) LGN differentiate
or Optic radiations Each referral should include the date,
(d) Visual Cortex
atrophy
4. Whichunless
of these associated
statements about with raised
the LGN is true? between the ‘true’ funnel type of full name of referring optometrist, their
intracranial pressure.
(a) The LGN is supplied The cerebral
by the anterior pupilartery.constricted visual field 10. At loss
whatwhere thevisualpractice
level of the address
pathway does andthat
the lesion contact
gives risetelephone
to this
(b) The LGNare
reactions receives input fromnormal.
typically both eyes. The breadth of the defect changes pair of visual
with field plots illustrated
the numberinand Figurethe
7a and b most likely
patients’ lie?
GP details in
(c) Pure optic tract or LGN lesions are relatively common. (a) Retina or Optic nerve
visual field
(d) The most common defects
cause of anare highly
LGN lesion distance at which the
is malignancy. (b) test or Optic Tract block capital letters. The full details of
is performed
Chiasm
congruous. There may be additional and the tunnel vision (c) that remains
LGN or the the patient, including their date of
Optic radiations
5. Which of these
neurological statements aboutincluding
disturbances an RAPD is false?same angular subtense (d) for
Visual Cortex test
different birth, NHS number (if known) and a
(a) It may be associated with normal visual acuity.
hallucinations, alexia and loss
(b) It can be quantified using a neutral density filter.
of distances, that is characteristic of a contact telephone number should be
11. At what level of the visual pathway does the lesion that gives rise to this
colour
(c) Opticperception.
nerve disordersRarely, if a lesion
can be differentiated malingering
from retinal cause. Thepair
disorders purely more common
of visual provided.
field plots illustrated in FigureThe
8a andreferral should
b most likely lie? be
should based on its findings.
damage the tip of one occipital causes are: (a) Retina or Optic nerve supported by a salient history, to
(d) It can
lobe, thebepatient
detected inmay the presence
complainof a totalof 3rd nerveEnd
palsy.stage glaucoma (b)that
Chiasm or Optic Tract include the prime complaint, its
is associated
(c) LGN or Optic rad iations
reading
6. Which ofdifficulties
these statements (despite
about chiasmalno lesionswith
is true? extensive optic cupping duration,
discCortex
(d) Visual whether constant,
apparent
(a) Bitemporalmacular
hemianopias abnormality)
always involve the and Retinitis
peripheral Pigmentosa, accompanied by intermittent, progressive or stationary
visual fields.
(b) Opticgrid
Amsler atrophy is an early
testing or sign of chiasmal
a ’central 10-2involvement.
retinal pigment clumping, 12. Whatdisc do the pallor
visual field plots
and illustrated
the timein of Figure 9a and
onset. Ablist
demonstrate?
of current
(c) Suprasellar masses are often associated with papilloedema. (a) Congruity
threshold programme with Humphrey
(d) In a child, an inferior bitemporal hemianopia suggests and attenuation of the retinal arteries.
(b) Preservation of foveal function medication may also prove useful (if
craniopharyngioma. (c) Fatigue
(d) Hemianopia

Please complete on-line by midnight on January 14 2009 - You will be unable to submit exams after this date – answers to the module will be published in our January 16 2009 issue