Visual Field Quiz
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Based on the visual field series shown, it appears the patient is experiencing lens artifact on the visual fields over time. The sharp nasal step seen on earlier fields is likely not real. My management would be: - Discontinue glaucoma treatment since visual fields are unreliable due to lens artifact - Perform gonioscopy and review optic nerve/retinal nerve fiber layer to evaluate for glaucoma - Consider cataract surgery to remove lens artifact on future visual fields - Counsel patient that visual fields were unreliable due to cataract and glaucoma status cannot be determined from VF alone The key things are to not rely solely on unreliable visual fields for glaucoma diagnosis or management, and address the underlying cause
Visual Field Quiz
- 1. Visual Field Quiz All that glitters isn’t glaucoma TBH 11th Sept 2015
- 4. What type of visual field defect might you expect to see in this patient?
- 5. Superior nasal step or superior arcuate scotoma due to the prominent notch in the optic nerve What is a likely diagnosis?
- 6. This is a Humphrey’s visual field from a man who comes in for a neurophthalmic eye examination 1. Describe the visual field defect 2. What is the likely cause of such a visual field defect? 3. What else can cause this visual defect? 4. What type of nystagmus can be associated with this field defect?
- 7. This is a Humphrey’s visual field from a man who comes in for a neuropthalmic eye examination 1. Describe the visual field defect • Incongruous bitemporal visual field defect that respects the mid-line 2. What is the likely cause of such a visual field defect? 3. What else can cause this visual defect? 4. What type of nystagmus can be associated with this field defect?
- 8. This is a Humphrey’s visual field from a man who comes in for a neuropthalmic eye examination 1. Describe the visual field defect • Incongruous bitemporal visual field defect that respects the mid-line 2. What is the likely cause of such a visual field defect? • A sellar chiasmal mass eg pituitary adenoma 3. What else can cause this visual defect? 4. What type of nystagmus can be associated with this field defect?
- 9. This is a Humphrey’s visual field from a man who comes in for a neuropthalmic eye examination 1. Describe the visual field defect • Incongruous bitemporal visual field defect that respects the mid-line 2. What is the likely cause of such a visual field defect? • A sellar chiasmal mass eg pituitary adenoma 3. What else can cause this visual defect? • Pseudo bitemporal field defects include: tilted optic discs, sectoral RP, optic nerve head drusen… 4. What type of nystagmus can be associated with this field defect?
- 10. This is a Humphrey’s visual field from a man who comes in for a neuropthalmic eye examination 1. Describe the visual field defect • Incongruous bitemporal visual field defect that respects the mid-line 2. What is the likely cause of such a visual field defect? • A sellar chiasmal mass eg pituitary adenoma 3. What else can cause this visual defect? • Pseudo bitemporal field defects include: tilted optic discs, sectoral RP, optic nerve head drusen… 4. What type of nystagmus can be associated with this field defect? • See-saw nystagmus which is conjugate clockwise then counterclockwise rotation of the eyes from 150-300 cycles per minute. There is elevation of the intorting eye and depression of the extorting eye which appears as if the eyes are see-sawing up and down
- 11. Patient wears thick spectacles High + or High -
- 12. Describe 9 sections of the visual field printout 1. 2. 3. 4. 5. 6. 7. 8. 9. 1 5 43 2 6 8 7 9 9
- 13. Describe 9 sections of the visual field printout 1. Test Selection and General Information 2. 5 43 2 6 8 7 9 9
- 14. Describe 9 sections of the visual field printout 1. Test Selection and General Information 2. Reliability Indices 3. 5 43 6 8 7 9 9
- 15. Describe 9 sections of the visual field printout 1. Test Selection and General Information 2. Reliability Indices 3. Numeric Results 4. 5 4 6 8 7 9 9
- 16. Describe 9 sections of the visual field printout 1. Test Selection and General Information 2. Reliability Indices 3. Numeric Results 4. Greyscale Results 5 6 8 7 9 9
- 17. Describe 9 sections of the visual field printout 1. Test Selection and General Information 2. Reliability Indices 3. Numeric Results 4. Greyscale Results 5. Total Deviation 6 8 7 9 9
- 18. Describe 9 sections of the visual field printout 1. Test Selection and General Information 2. Reliability Indices 3. Numeric Results 4. Greyscale Results 5. Total Deviation 6. Pattern Deviation 8 7 9 9
- 19. Describe 9 sections of the visual field printout 1. Test Selection and General Information 2. Reliability Indices 3. Numeric Results 4. Greyscale Results 5. Total Deviation 6. Pattern Deviation 7. Glaucoma Hemifield Test 8 9 9
- 20. Describe 9 sections of the visual field printout 1. Test Selection and General Information 2. Reliability Indices 3. Numeric Results 4. Greyscale Results 5. Total Deviation 6. Pattern Deviation 7. Glaucoma Hemifield Test 8. Global Indices 9 9
- 21. Describe 9 sections of the visual field printout 1. Test Selection and General Information 2. Reliability Indices 3. Numeric Results 4. Greyscale Results 5. Total Deviation 6. Pattern Deviation 7. Glaucoma Hemifield Test 8. Global Indices 9. Probability Symbols and Gaze Graph
- 22. Where is the likely pathology?
- 23. Where is the likely pathology? • Cataract
- 24. Describe the visual field and most likely diagnosis
- 25. Describe the visual field and most likely diagnosis • POAG – nasal step
- 26. Describe the visual field and most likely diagnosis
- 27. Describe the visual field and most likely diagnosis • POAG
- 29. What happened here? - lens holder artifact. Sharp fall off with absent nasal step = artifactual
- 30. Both patients scored 3/14 fixation losses. What is the difference between the two patients?
- 31. Describe the field. Any explanation?
- 32. Describe the field. Any explanation? • Clover leaf = patient fatigue
- 33. This is not glaucoma. What is another likely diagnosis?
- 34. This is not glaucoma. What is another likely diagnosis? • Age related macular degeneration
- 35. This is not glaucoma. What is another likely diagnosis?
- 36. This is not glaucoma. What is another likely diagnosis? • Retinitis Pigmentosa
- 37. An 85 year old woman with mild ocular hypertension, but a healthy optic nerve was diagnosed with glaucoma based on the appearance of the VF. Without seeing the patient what do you suspect?
- 38. An 85 year old woman with mild ocular hypertension, but a healthy optic nerve was diagnosed with glaucoma based on the appearance of the VF. Without seeing the patient what do you suspect? • Involutional Ptosis
- 39. 60 year old woman says that she needs a pressure check. She has been treated for glaucoma for 3 years with a prostoglandin analog in both eyes. VA 6/6 OU, IOP 14 OU, VF = superior arcuate defect in the left eye. Right optic nerve is normal, left optic nerve shown below 1. What does her optic nerve photo show? 2. What is the pathophysiology 3. What tests can confirm? 4. What is your management?
- 40. 60 year old woman: 1. Optic nerve head drusen 2. Calcified hylaline bodies in prelaminar optic nerve 3. B-scan, CT, AF 4. ?Glaucoma or drusen? 1. VF stable? 2. IOP over time? 3. Any changes in ON appearance? 4. If no baseline?
- 41. 60 year old woman: 1. Optic nerve head drusen 2. Calcified hylaline bodies in prelaminar optic nerve 3. B-scan, CT, AF 4. ?Glaucoma or drusen? 1. VF stable? 2. IOP over time? 3. Any changes in ON appearance? 4. If no baseline? • VF, Gonio, CCT, ON images
- 42. 60 year old woman: 1. Optic nerve head drusen 2. Calcified hylaline bodies in prelaminar optic nerve 3. B-scan, CT, AF 4. ?Glaucoma or drusen? 1. VF stable? 2. IOP over time? 3. Any changes in ON appearance? 4. If no baseline? • VF, Gonio, CCT, ON images
- 43. 63 year old man reports difficulty in reading. He says that the words are clear, but he has trouble following the lines of text and loses his place. He denies any change in vision, headaches, or other neurologic symptoms. Exam shows visual acuity of 6/6 in both eyes at distance and near, normal pupillary response without a RAPD, very early cataract and normal fundus exam. Q: What other tests would you perform?
- 44. 63 year old man reports difficulty in reading. He says that the words are clear, but he has trouble following the lines of text and loses his place. He denies any change in vision, headaches, or other neurologic symptoms. Exam shows visual acuity of 6/6 in both eyes at distance and near, normal pupillary response without a RAPD, very early cataract and normal fundus exam. Q: What other tests would you perform? EOM, Amsler and VF Additional information: Extraocular motility is full and the eyes are orthsphoric. Amsler grid reveals a blurry area inferotemporal to fixation in the right eye… Humphrey VF testing on next slide…
- 45. Q: What does the VF test show? Q: Where is the pathology? Q: What would you do next?
- 46. Q: What does the VF test show? Right homonymous inferior quadrantic scotomas Q: Where is the pathology? Left Parietal Lobe Q: What would you do next? Neuroimaging
- 47. You find a VF lying on a table in the clinic with no name… You try to find the patient… Q: How might the patient present? Q: What signs would you find?
- 48. This patient has been treated for glaucoma for 2 years due to findings on her VF. The VF series is sent to you for opinion. What is happening? What would your management be?