Visual field

The visual field is "that portion of space in which objects are visible at the same moment during steady fixation of the gaze in one direction";[1] in ophthalmology and neurology the emphasis is on the structure inside the visual field and it is then considered “the field of functional capacity obtained and recorded by means of perimetry”.[2][3][4]

However, the visual field can also be understood as a predominantly perceptual concept and its definition then becomes that of the "spatial array of visual sensations available to observation in introspectionist psychological experiments"[5] (for example in van Doorn et al., 2013).[6]

The corresponding concept for optical instruments and image sensors is the field of view (FOV). In humans and animals, the FOV refers to the area visible when eye movements – if possible for the species – are allowed.

In optometry, ophthalmology, and neurology, a visual field test is used to determine whether the visual field is affected by diseases that cause local scotoma or a more extensive loss of vision or a reduction in sensitivity (increase in threshold).

Normal limits
The classical image on the shape and size of the visual field by Harry Moss Traquair in his book Clinical Perimetry (1938; modified to show the essentials). It shows that the visual field is considerably larger on the temporal side than the often quoted 90° extent. Similar limits were already reported in the 19th century.

The normal (monocular) human visual field extends to approximately 60 degrees nasally (toward the nose, or inward) from the vertical meridian in each eye, to 107 degrees temporally (away from the nose, or outwards) from the vertical meridian, and approximately 70 degrees above and 80 below the horizontal meridian.[7][1][8][9]

The binocular visual field is the superimposition of the two monocular fields. In the binocular field, the area left of the vertical meridian is referred to as the left visual field (which is located temporally for the left, and nasally for the right eye); a corresponding definition holds for the right visual field. The four areas delimited by the vertical and horizontal meridian are referred to as upper/lower left/right quadrants. In the European Union, the minimum field requirement for driving is 50 degrees to either side of the vertical meridian and 120 degrees horizontally in total, and 20 degrees above and below the horizontal meridian. The macula corresponds to the central 17 degrees diameter of the visual field; the fovea to the central 5.2 degrees, and the foveola to 1–1.2 degrees diameter.[10][11] Note that in the clinical literature the fovea can refer to the central 1–1.2 deg, i.e. what is otherwise known as the foveola, and can be referred to as the "clinical fovea".[12]

The nose is situated in the field of view of both eyes, but due to later processing carried out in the brain, it is not noticed during normal visual tasks.

Measuring the visual field
Main article: visual field test

The visual field is measured by perimetry. This may be kinetic, where spots of light are shown on the white interior of a half sphere and slowly moved inwards until the observer sees them, or static, where the light spots are flashed at varying intensities at fixed locations in the sphere until detected by the subject. Commonly used perimeters are the automated Humphrey Field Analyzer, Optopol Perimeters, Octopus, the Heidelberg Edge Perimeter, or the Oculus.

Another method is to use a campimeter, a small device with a flat screen designed to measure the central visual field.

Light spot patterns testing the central 24 degrees or 30 degrees of the visual field, are most commonly used. Most perimeters are also capable of testing up to 80 or 90 or even 120 degrees.

Another method is for the practitioner to hold up one, two, or five fingers in the four quadrants and center of a patient's visual field (with the other eye covered). This is also known as confrontational field testing. If the patient is able to report the number of fingers properly as compared with the visual field of the practitioner, the normal result is recorded as "full to finger counting" (often abbreviated FTFC). The blind spot can also be assessed via holding a small object between the practitioner and the patient. By comparing when the object disappears for the practitioner, a subject's blind spot can be identified. There are many variants of this type of exam (e.g., wiggling fingers in the visual periphery on the cardinal axes).

Visual field loss

Visual field loss may occur due to many disease or disorders of the eye, optic nerve, or brain. For the eye, e.g., Glaucoma causes peripheral field defects. Macular degeneration and other diseases affecting the macula cause central field defects. Lesions of the visual pathway cause characteristic forms of visual disturbances, including homonymous hemianopsia, quadrantanopsia, and scotomata.

The main classification of visual field defects is into

  1. Lesions to the eye's retina (heteronymous field defects in Glaucoma and AMD)
  2. Lesions of the optic nerve (heteronymous field defects)
  3. Lesions in the chiasm (e.g. Bitemporal hemianopia, loss of vision at the sides)
  4. Lesions after the chiasm (homonymous field defects like homonymous hemianopia, Quadrantanopia, homonymous scotomata)

Other characterisations are:

  1. Altitudinal field defects, loss of vision above or below the horizontal meridian – associated with ocular abnormalities
  2. Central scotoma, loss of central vision
  3. Peripheral field loss including tunnel vision
  4. Generalized depression of the entire field of vision [13]

Visual field defects in glaucoma

In glaucoma, visual field defects result from damage to the retinal nerve fiber layer. Field defects are seen mainly in primary open angle glaucoma. Because of the unique anatomy of the RNFL, many noticeable patterns are seen in the visual field. Most of the early glaucomatous changes are seen within the central visual field, mainly in Bjerrum's area, 10°-20° from fixation.[14]

Following are the common glaucomatous field defects:

Bjerrum's area and types of scotomas on the visual field
  • Generalized depression: Generalized depression is seen in early stages of glaucoma and many other conditions. Mild constriction of the central and peripheral visual field due to isopter contraction comes under generalized depression. If all the isopters show similar depression to the same point, it is called a contraction of the visual field. Relative paracentral scotomas are the areas where smaller and dimmer targets are not detected by the patient.[14] Larger and brighter targets can be seen. Small paracentral depressions, mainly superonasal, occur in normal-tension glaucoma (NTG).[15] The generalized depression of the entire field may occur in cataract also.[13]
  • Baring of blind spot: Baring of the blind spot means the exclusion of the blind spot from the central field due to inward curve of the outer boundary of the 30° central field.[16] It is only an early, non-specific visual field change, without much diagnostic value in glaucoma.[16]
  • Small wing-shaped paracentral scotoma: Small wing-shaped paracentral scotoma within Bjerrum's area is the earliest clinically significant field defect seen in glaucoma. It may also be associated with nasal steps. Scotoma may be seen above or below the blind spot.[16]
  • Siedel's sickle-shaped scotoma: Paracentral scotoma joins with the blind spot to form Siedel's sickle-shaped scotoma.
  • Arcuate or Bjerrum's scotoma: This kind of scotoma is formed at later stages of glaucoma by extension of Seidel's scotoma in an area either above or below the fixation point to reach the horizontal line. Peripheral breakthrough may occur due to damage of nerve fibers.[16]
  • Ring or double arcuate scotoma: Two arcuate scotomas join to form a ring or double arcuate scotoma. This defect is seen in advanced stages of glaucoma.
  • Roenne's central nasal step: It is created when two arcuate scotomas run in different arcs to form a right angled defect. This is also seen in advanced stages of glaucoma.
  • Peripheral field defects: Peripheral field defects may occur in early or late stages of glaucoma. Roenne's peripheral nasal steps occur due to contraction of peripheral isopter.[16]
  • Tubular vision: Since macular fibers are the most resistant to glaucomatous damage, central vision remains unaffected until the end stages of glaucoma. It results in tubular vision, or tunnel vision, by the loss of peripheral vision with retention of central vision, resulting in a constricted circular tunnel-like field of vision. Retinitis pigmentosa is another disease that causes tubular vision.[17]
  • Temporal island of vision: It is also seen in end stages of glaucoma. The temporal islands lie outside of the central 24 to 30° visual field,[18] so it may not be visible with standard central field measurements done in glaucoma.

Field defects in macular degeneration (AMD)
Main article: Macular degeneration

The macula of the retina is the central area in the visual field of about 10 to 17 deg diameter (in visual angle). It is responsible for high-resolution vision in good light, in particular for reading. Many diseases affecting the macula may cause defects in the central field of vision, among them metamorphopsia and central scotomas.

Field defects in visual pathway lesions
Main article: Visual pathway lesions
See also: Visual system
Visual pathway lesions
From top to bottom:
1. Complete loss of vision in the right eye
2. Bitemporal hemianopia
3. Homonymous hemianopia
4. Quadrantanopia
5. & 6. Quadrantanopia with macular sparing

The visual pathway consists of structures that carry visual information from the retina to the brain. Lesions in the pathway cause a variety of visual field defects. The type of field defect can help localize where the lesion is located (see figure).

Neurological causes of visual field defects
  • Cerebral palsy: Field loss due to cerebral palsy may be hemianopic affecting even upper or lower half, central scotoma, peripheral scotoma, or islands of vision.[20]
  • Epilepsy: Although field defects are rarely associated with epilepsy,[21] defects may occur after temporal lobe surgery for epilepsy.[22]
  • Periventricular leukomalacia (PVL): Bilateral inferior visual field defects may occur due to damage of the optic radiations.[23]

Other causes of field defects

The following illustrations are a rough attempt at visualizing a number of visual field defects. Note that they do not (and cannot) visualize the percept (i.e. what is seen by the observer). For example, the visual fields for the two eyes are seen as one field. The missing areas are not seen as white or black – they are simply invisible to the observer, who is, furthermore, typically unaware that they are invisible.


See also

References
  1. Traquair, Harry Moss (1938). An Introduction to Clinical Perimetry, Chpt. 1. London: Henry Kimpton.
  2. Aulhorn, Elfriede; Harms, Heinrich (1972). Visual Perimetry. In: Handbook of Sensory Physiology book series (1536, volume 7/4. pp. 102–145. doi:10.1007/978-3-642-88658-4_5.
  3. A related definition is “The visual field refers to the area visible during stable fixation of the eyes, specified in degrees of visual angle.”
  4. Strasburger, Hans; Pöppel, Ernst (2002). Visual Field. In G. Adelman & B.H. Smith (Eds): Encyclopedia of Neuroscience; 3rd edition, on CD-ROM. Elsevier Science B.V., Amsterdam, New York.
  5. Smythies, J (1996). "A note on the concept of the visual field in neurology, psychology, and visual neuroscience". Perception. 25 (3): 369–71. doi:10.1068/p250369. PMID 8804101. S2CID 27088663.
  6. van Doorn, Andrea; Koenderink, Jan; Wagemans, Johan (2013). "Exocentric pointing in the visual field". i-Perception. 4: 532–542. doi:10.1068/i0609. PMC 4129387. PMID 8804101.
  7. Rönne, Henning (1915). "Zur Theorie und Technik der Bjerrrumschen Gesichtsfelduntersuchung". Archiv für Augenheilkunde. 78 (4): 284–301.
  8. Robert H. Spector (1990). "Visual Fields". Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Butterworths. ISBN 9780409900774.
  9. Similar limits were already reported in the 19th century by Alexander Hueck (1840, p. 84): „Outwards from the line of sight I found an extent of 110°, inwards only 70°, downwards 95°, upwards 85°. When looking into the distance we thus overlook 220° of the horizon." Hueck, A. (1840). Von den Gränzen des Sehvermögens. Archiv für Anatomie, Physiologie und wissenschaftliche Medicin, 82-97.
  10. Strasburger, H.; Rentschler, I.; Jüttner, M. (2011). "Peripheral vision and pattern recognition: a review". Journal of Vision. 11 (5): 1–82. doi:10.1167/11.5.13. PMID 22207654.
  11. Polyak, S. L. (1941). The Retina. Chicago: The University of Chicago Press.
  12. Strasburger, Hans (2020). "Seven myths on crowding and peripheral vision". i-Perception. 11 (2): 1–45.
  13. Joy N. Carroll; Chris A. Johnson (2013-08-22). "Visual Field Testing: From One Medical Student to Another".
  14. "Glaucoma". Parsons' diseases of the eye (22 ed.). Elsevier. 15 July 2015. pp. 288–295. ISBN 978-81-312-3818-9.
  15. John F, Salmon. "Glaucoma". Kanski's Clinical ophthalmology (9 ed.). Elsevier. pp. 362–365.
  16. Khurana (31 August 2015). "Glaucoma". Comprehensive ophthalmology (6th ed.). Jaypee, The Health Sciences Publisher. pp. 223–224. ISBN 978-93-5152-657-5.
  17. "Retinitis pigmentosa". Genetics Home Reference.
  18. Themes, U. F. O. (11 July 2016). "Visual Fields in Glaucoma". Ento Key.
  19. Khurana (31 August 2015). "Neuro-ophthalmology". Comprehensive ophthalmology (6th ed.). Jaypee, The Health Sciences Publisher. pp. 314–315. ISBN 978-93-5152-657-5.
  20. "Cerebral Palsy and Children with Vision and Hearing Loss". www.tsbvi.edu.
  21. G, Valli; S, Zago; A, Cappellari; A, Bersano (1999). "Transitory and Permanent Visual Field Defects Induced by Occipital Lobe Seizures". Italian Journal of Neurological Sciences. 20 (5): 321–5. doi:10.1007/s100720050048. PMID 10933442. S2CID 22141996.
  22. Manji, H.; Plant, G. T. (1 January 2000). "Epilepsy surgery, visual fields, and driving: a study of the visual field criteria for driving in patients after temporal lobe epilepsy surgery with a comparison of Goldmann and Esterman perimetry". Journal of Neurology, Neurosurgery & Psychiatry. 68 (1): 80–82. doi:10.1136/jnnp.68.1.80. ISSN 0022-3050. PMC 1760599. PMID 10601407.
  23. Kozeis, N (2010). "Brain visual impairment in childhood: mini review". Hippokratia. 14 (4): 249–251. ISSN 1108-4189. PMC 3031318. PMID 21311632.
  24. Benjamin Osborne; Laura J Balcer. "Optic neuritis: Pathophysiology, clinical features, and diagnosis". www.uptodate.com.
  25. "Leber Hereditary Optic Neuropathy". NORD (National Organization for Rare Disorders).
  26. "Macular Hole - The American Society of Retina Specialists". www.asrs.org.
  27. "Cone Dystrophy". NORD (National Organization for Rare Disorders).
  28. "Eye Occlusions, Blockages or Eye Strokes". All About Vision.
  29. "Retinitis Pigmentosa Symptoms". American Academy of Ophthalmology. 30 October 2019.
  30. Elgin, Jennifer; McGwin, Gerald; Wood, Joanne M.; Vaphiades, Michael S.; Braswell, Ronald A.; DeCarlo, Dawn K.; Kline, Lanning B.; Owsley, Cynthia (2010). "Evaluation of On-Road Driving in Persons with Hemianopia and Quadrantanopia". The American Journal of Occupational Therapy. 64 (2): 268–278. doi:10.5014/ajot.64.2.268. ISSN 0272-9490. PMC 2964938. PMID 20437914.
  31. Akash Raj. "ALTITUDINAL VISUAL FIELD DEFECT" (PDF). Journal of the Bombay Ophthalmologists' Association. 11: 127.
  32. "Age-related Macular Degeneration". 22 October 2013. Archived from the original (JPG) on 2013-10-22. Retrieved 2023-04-03.
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