Visual Field Tests: Types, Results, Reliability and What to Expect

Author: Dr Val Phua
Estimated reading time: 23 minutes

a person can see while looking straight ahead.

It assesses central and peripheral vision, including areas above, below and to either side of fixation.

Visual field testing is used to diagnose and monitor conditions affecting:

• The retina
• The optic nerve
• The visual pathways within the brain
• The eyelids and orbit
• The neurological system

It is especially important in glaucoma because glaucoma commonly damages peripheral or paracentral vision before the patient notices symptoms.

Visual field testing may also be used for:

• Optic neuritis
• Ischaemic optic neuropathy
• Pituitary tumours
• Stroke
• Papilloedema
• Retinal detachment
• Retinal vascular disease
• Retinitis pigmentosa
• Hydroxychloroquine screening
• Ptosis
• Driving or occupational assessments
• Unexplained visual symptoms

The most commonly used clinical test is standard automated perimetry.

During this test:

• One eye is covered.
• The patient looks steadily at a central target.
• Small lights appear briefly in different locations.
• The patient presses a button whenever a light is seen.
• The machine maps the dimmest light detected at each tested point.

Visual field testing is safe and non-invasive.

However, it is a subjective test.

The result depends on:

• Fixation
• Attention
• Understanding
• Reaction time
• Fatigue
• Scan strategy
• Refractive correction
• Pupil size
• Cataract or other media opacity
• Previous testing experience

A single abnormal visual field does not always prove disease or progression.

The result should be interpreted alongside:

• Symptoms
• Visual acuity
• Eye pressure
• Optic-nerve examination
• OCT imaging
• Retinal examination
• Previous visual fields
• Neurological findings where relevant

Modern perimetry remains the reference standard for measuring functional visual-field loss, but test variability and artefacts make careful review of the complete test more important than relying on a single summary number or computer-generated label. Answer

What Is the Visual Field?

The visual field is everything visible while the eyes remain directed at one point.

It includes:

• Central vision
• Paracentral vision
• Peripheral vision
• Upper and lower fields
• Nasal and temporal fields

Each eye has its own monocular visual field.

When both eyes are open, the two fields overlap to create a binocular visual field.

Is a Visual Field Test the Same as an Eyesight Test?

No.

A visual-acuity chart measures how clearly the patient sees small central letters.

A visual field test measures where the patient can see.

A patient may have:

• 6/6 central visual acuity
• Good reading vision
• Significant peripheral visual-field loss

This is one reason glaucoma can remain unnoticed until relatively advanced.

What Does the Patient Do?

The patient looks at a central target and presses a response button whenever a light is seen.

The test does not require the patient to identify:

• Letters
• Colours
• Shapes
• Directions

The patient should respond only when a light is genuinely seen.

Is the Test Painful?

No.

Visual field testing is non-invasive and should not be painful.

Patients may experience:

• Tiredness
• Dryness
• Difficulty maintaining concentration
• Neck or back discomfort
• Anxiety about missing lights

There is no penalty for missing lights that are too dim to see.

How Long Does It Take?

A routine threshold test commonly takes approximately:

• Two to seven minutes per eye with modern algorithms
• Longer when the field loss is advanced
• Longer when fixation is poor
• Longer when a wider or more detailed test pattern is required

SITA Faster can substantially shorten test duration compared with SITA Standard while producing broadly comparable global results, particularly in mild-to-moderate glaucoma. Each Eye Be Tested Separately?

A defect in one eye may be masked by the other eye when both eyes are open.

Monocular testing helps determine:

• Which eye is affected
• The location of the defect
• Whether the pattern respects the horizontal or vertical meridian
• Whether the two eyes show corresponding or different abnormalities

Binocular testing may be performed separately when the purpose is to assess functional vision with both eyes open.

Can a Person “Fail” a Visual Field Test?

A visual field is not normally described as a simple pass-or-fail test unless it is being used for a specific:

• Driving standard
• Occupational standard
• Disability assessment
• Licensing requirement

For medical diagnosis, the ophthalmologist assesses:

• The pattern
• Depth
• Extent
• Reliability
• Reproducibility
• Change over time

Understanding Normal Vision

Central Vision

Central vision is used for:

• Reading
• Recognising faces
• Looking at fine detail
• Colour discrimination
• Driving
• Precise hand-eye coordination

The central visual field is measured particularly densely with tests such as the 10-2 program.

Peripheral Vision

Peripheral vision contributes to:

• Mobility
• Orientation
• Detecting approaching objects
• Navigating crowds
• Avoiding obstacles
• Driving
• Function in dim lighting

Peripheral loss may be difficult to notice because:

• It often develops gradually.
• The other eye may compensate.
• The brain may fill in missing information.
• Patients naturally move their eyes and head during daily life.

The Natural Blind Spot

Each eye has a normal blind spot where the optic nerve leaves the retina.

There are no photoreceptors at this location.

The brain normally fills in the missing area, so the blind spot is not noticed during daily vision.

The perimeter may use the blind spot to help monitor fixation.

What Is Perimetry?

Perimetry is the measurement of the visual field.

The term comes from testing visual sensitivity across the area surrounding fixation.

A perimeter is the instrument used to perform the test.

Static Perimetry

During static perimetry:

• The stimulus remains in one location.
• Its brightness changes.
• The machine determines whether the patient detects it.

Standard automated perimetry is a form of static perimetry.

Kinetic Perimetry

During kinetic perimetry:

• A light is moved from a non-seeing area towards a seeing area.
• The patient responds when it becomes visible.
• Points of equal sensitivity are connected to form boundaries called isopters.

Kinetic testing is useful when:

• The peripheral field needs detailed mapping
• The patient has severe field constriction
• Neurological disease is suspected
• Retinal dystrophy is present
• Automated static testing is difficult
• The patient has advanced visual-field loss

Automated Perimetry

Automated perimetry uses computer-controlled:

• Stimulus brightness
• Stimulus timing
• Test locations
• Threshold calculations
• Reliability monitoring
• Statistical analysis

The Humphrey Field Analyzer and Octopus perimeter are commonly used examples.

Results from different devices, grids and algorithms should not automatically be treated as directly interchangeable.

Confrontation Visual Fields

Confrontation testing is performed during a clinical examination.

The patient covers one eye and looks at the examiner while:

• Fingers are counted
• A moving target is detected
• Red colour is compared
• Both sides are tested simultaneously

Confrontation testing is useful for detecting large defects.

It may miss:

• Early glaucoma
• Small paracentral defects
• Shallow defects
• Subtle neurological abnormalities

A normal confrontation field does not replace formal perimetry when disease is suspected.

Amsler Grid Testing

An Amsler grid assesses the central field and distortion.

It may help patients monitor conditions such as:

• Macular degeneration
• Epiretinal membrane
• Macular disease

It does not replace formal perimetry because it does not measure visual sensitivity across the broader field.

Microperimetry

Microperimetry combines:

• Retinal imaging
• Eye tracking
• Point-by-point sensitivity testing

It projects stimuli onto known retinal locations.

It may be useful in:

• Macular degeneration
• Inherited retinal disease
• Macular holes
• Diabetic macular disease
• Low vision
• Assessment of fixation stability

Unlike routine automated perimetry, microperimetry can relate visual sensitivity directly to visible retinal anatomy.

Frequency-Doubling Technology Perimetry

Frequency-doubling technology, or FDT, presents low-spatial-frequency striped targets that flicker rapidly.

It may be used for:

• Glaucoma screening
• Functional assessment
• Portable or faster testing

FDT can detect moderate and severe glaucoma effectively and may identify some abnormalities not seen on conventional testing, but standard automated perimetry remains the principal reference test for monitoring established glaucoma. elength Automated Perimetry

Short-wavelength automated perimetry uses a blue stimulus on a yellow background.

It was developed to test selected retinal pathways that may be affected early in glaucoma.

Limitations include:

• Longer testing
• Greater variability
• Greater sensitivity to cataract
• Greater learning effects
• Reduced tolerability

It is less commonly used in routine glaucoma care than standard white-on-white automated perimetry.

How Standard Automated Perimetry Works

Background Illumination

The patient looks into a softly illuminated bowl.

A constant background helps standardise retinal adaptation.

Test Stimuli

Small white lights are presented briefly at predetermined locations.

The brightness changes according to the patient’s responses.

Threshold Sensitivity

The threshold is the dimmest stimulus the patient detects at a location under the test conditions.

The perimeter estimates rather than measures an absolute biological boundary.

Repeated measurements at the same point can differ.

Decibels

Visual-field sensitivity is expressed in decibels, abbreviated as dB.

A higher decibel value means:

• Greater sensitivity
• The ability to detect a dimmer stimulus

A lower decibel value means:

• Reduced sensitivity
• A brighter stimulus is required

The decibel scale is logarithmic rather than linear.

A reduction of 10 dB represents approximately a tenfold reduction in measured sensitivity.

Stimulus Size

The most commonly used standard automated perimetry stimulus is Goldmann size III.

Larger targets may be useful in:

• Advanced glaucoma
• Severe retinal disease
• Poor vision
• Unstable fixation

A larger stimulus may reduce variability and extend the measurable range in severely damaged areas, but results cannot be compared directly with earlier size III tests without caution.

Common Humphrey Visual Field Programs

The 24-2 Test

The 24-2 is one of the most commonly used visual-field patterns for glaucoma.

It samples:

• The central field
• The nasal field farther from fixation
• Superior and inferior arcuate regions

Test points are generally six degrees apart.

It provides a broad overview of the central and near-peripheral field but samples the central ten degrees relatively sparsely.

The 30-2 Test

The 30-2 tests a slightly wider central area than the 24-2.

It is commonly used in:

• Neuro-ophthalmology
• Optic-nerve disease
• Chiasmal disease
• Selected glaucoma assessments
• Unexplained visual loss

The additional peripheral points may provide useful information but increase testing time.

The 10-2 Test

The 10-2 tests the central ten degrees using points approximately two degrees apart.

It is useful for:

• Paracentral glaucoma
• Advanced glaucoma with a small central island
• Normal-tension glaucoma
• Macular disease
• Hydroxychloroquine screening
• Optic-nerve disease affecting fixation

The standard 24-2 contains 54 tested locations, whereas the 10-2 contains 68 locations concentrated within the central ten degrees. oes not replace a wider field when peripheral damage also needs assessment.

The 24-2C Test

The 24-2C combines the standard 24-2 pattern with ten additional central points selected from locations commonly affected by glaucoma.

It is designed to improve detection of central defects without requiring a separate full 10-2 test in every patient.

Studies show that 24-2C detects more central defective locations than conventional 24-2 and can provide an efficient initial assessment. However, the denser 10-2 still samples substantially more central points and remains useful when a paracentral defect is suspected or already established. and Wider-Field Programs

Wider programs may be used to assess:

• Far peripheral vision
• Retinal dystrophies
• Neurological disease
• Severe field constriction
• Functional disability

Kinetic perimetry may provide a more practical map of the far periphery in some patients.

Esterman Binocular Visual Field Testing

The Esterman test measures visual-field function with both eyes open.

It uses a weighted grid of test locations.

The binocular Esterman test may be used for:

• Driving assessments
• Occupational assessments
• Disability evaluation
• Functional assessment in advanced disease

It does not provide the same threshold detail as monocular glaucoma testing.

A person can have substantial monocular loss but retain a better binocular result because the two eyes compensate for one another.

The Esterman test is widely used in driving-related assessment, although reliability and the legal interpretation of results vary by jurisdiction. Between 24-2, 24-2C and 10-2

A 24-2 May Be Chosen When

• A general glaucoma baseline is required
• Peripheral arcuate damage is being monitored
• No central defect is suspected
• Previous serial tests used the same pattern

A 24-2C May Be Chosen When

• Both peripheral and central sampling are desirable
• A faster initial test is preferred
• Early glaucoma is suspected
• Central damage needs better representation than standard 24-2 provides

A 10-2 May Be Chosen When

• A paracentral defect is present
• OCT shows macular ganglion-cell damage
• Fixation-threatening glaucoma is suspected
• The 24-2 result does not explain symptoms
• Advanced glaucoma leaves a small central island
• Detailed central progression needs monitoring

A 2026 prospective study found that global and sectoral progression estimates from 10-2 and central 24-2 locations were broadly similar in early glaucoma. The 10-2 provided additional pointwise information in patients with selectively worse central damage and faster local progression. ould therefore be based on the location and stage of disease rather than assuming that one grid is universally superior.

SITA Testing Strategies

SITA stands for Swedish Interactive Thresholding Algorithm.

It estimates visual-field thresholds efficiently by using:

• Previous responses
• Age-related expectations
• Neighbouring test locations
• Statistical models
• Response timing

SITA Standard

SITA Standard is a well-established threshold strategy.

Advantages include:

• Extensive longitudinal experience
• Good threshold precision
• Broad use in clinical trials
• Familiarity for serial comparison

Its main disadvantage is longer test duration.

SITA Fast

SITA Fast shortens the test by using less extensive threshold refinement.

It may improve tolerance while producing slightly different sensitivity estimates from SITA Standard.

SITA Faster

SITA Faster further reduces testing time.

Studies have shown approximately 50% to 60% shorter test durations than SITA Standard, with broadly comparable mean deviation, visual-field index and test-retest variability. Small differences remain, particularly in advanced loss, and switching strategy may warrant a new or carefully interpreted baseline. ng Be Too Fast?

Shorter testing can reduce:

• Fatigue
• Loss of attention
• Clinic time

However, rapid testing does not remove:

• Response variability
• False-positive responses
• Learning effects
• Fixation errors
• The need to confirm abnormalities

The best strategy is the one that provides sufficiently reliable information for that patient and allows meaningful comparison over time.

What Happens During a Visual Field Test?

Step 1: Confirming the Test

The operator confirms:

• Patient identity
• Eye being tested
• Test pattern
• Testing strategy
• Refractive correction
• Previous visual fields

Step 2: Correcting Near Focus

A trial lens may be placed in front of the eye.

The appropriate lens depends on:

• Age
• Distance prescription
• Test distance
• Test program
• Aphakia or pseudophakia

Incorrect refractive correction can cause diffuse blur and reduced sensitivity.

Step 3: Covering One Eye

The non-tested eye is covered completely.

The patch should not press on the covered eye or interfere with the tested eye.

Step 4: Positioning

The patient rests the chin and forehead against the machine.

Correct positioning helps prevent:

• Lens-rim artefact
• Eyelid obstruction
• Loss of fixation
• Poor alignment

Step 5: Finding the Fixation Target

The patient looks steadily at a central light or pattern.

The central fixation target should remain the focus throughout the test.

The patient should not look around for each flash.

Step 6: Testing the Response Button

A visible test light may be shown so the patient understands when to press.

Step 7: Presenting Stimuli

Lights appear briefly in different locations and at different brightness levels.

Some presentations are deliberately too dim to see.

The patient should not press simply because a light is expected.

Step 8: Monitoring Fixation and Reliability

The instrument or operator may monitor:

• The pupil
• Eye position
• Gaze tracking
• Blind-spot responses
• Response timing
• False-positive responses

Step 9: Pausing When Necessary

The patient may ask to pause when:

• The eye is dry
• Positioning is uncomfortable
• Concentration is lost
• The test instructions are unclear

A short pause is preferable to continuing with an unreliable test.

How to Perform the Test Well

Keep Looking at the Centre

Do not follow the flashes.

Peripheral vision is being tested while fixation remains central.

Press Only When a Light Is Seen

It is normal to miss many stimuli.

Some lights are intentionally below the patient’s threshold.

Do Not Wait for Perfect Certainty

Some threshold lights are very faint.

Press when a light is genuinely perceived, even if it is dim.

Blink Normally

The patient may blink normally between stimuli.

Briefly blinking when the machine is quiet can improve comfort and image clarity.

Ask for a Pause

A pause may help when:

• The eye feels dry
• The patient loses concentration
• The forehead moves away
• The trial lens touches the eyelashes

Avoid Excessive Guessing

Frequent guessing may produce false-positive errors and make the field appear artificially better than it is.

Do Not Worry About Making Mistakes

Perimetry is designed to estimate sensitivity despite some response variability.

Anxiety and overthinking can make the test less reliable.

Preparing for the Test

Patients should generally:

• Bring their current spectacles
• Bring a list of eye conditions and medication
• Use prescribed glaucoma drops normally unless advised otherwise
• Inform the operator about neck, back or mobility limitations
• Ask for an explanation before starting
• Avoid rushing immediately after strenuous activity
• Rest briefly if tired

Should Contact Lenses Be Removed?

This depends on:

• Contact-lens type
• Optical correction required
• Dryness
• Test protocol
• Clinic preference

Contact lenses may worsen dryness during a prolonged test.

Rigid or poorly centred lenses may affect vision or comfort.

Should the Patient Have Caffeine?

Ordinary caffeine intake does not usually prevent testing.

A patient who becomes tremulous or anxious after caffeine may find concentration more difficult.

Consistency between visits may be useful when small changes are being assessed.

Can the Test Be Performed After Pupil Dilation?

Yes, but dilation may:

• Blur near focus
• Change retinal illumination
• Require revised trial-lens correction
• Increase discomfort from light

Whenever possible, serial glaucoma fields are performed under reasonably comparable conditions.

Reading a Visual Field Report

A visual field report contains several maps, numbers and statistical analyses.

No single part should be interpreted in isolation.

The Grey Scale

The grey scale gives an intuitive visual representation of sensitivity.

Darker areas generally indicate lower sensitivity.

It is useful for recognising broad patterns but may exaggerate small changes.

Clinical interpretation should rely more heavily on:

• Threshold values
• Deviation plots
• Reliability data
• Serial comparison

Threshold Values

Each tested point displays a sensitivity value in decibels.

Sensitivity normally decreases:

• With age
• Farther from fixation
• In certain physiological regions

A low value may represent:

• True disease
• Cataract
• Poor fixation
• Artefact
• Fatigue
• Normal anatomical variation

Total Deviation Plot

The total deviation plot compares each measured point with the age-adjusted expected sensitivity.

It shows the combined effect of:

• Localised defects
• Generalised depression

Generalised depression may occur with:

• Cataract
• Uncorrected refractive error
• Small pupil
• Diffuse retinal disease
• Advanced glaucoma

Pattern Deviation Plot

The pattern deviation analysis adjusts for an overall shift in the field.

It is designed to highlight localised defects after accounting for generalised depression.

It may be helpful in distinguishing:

• Cataract-related diffuse reduction
• Localised glaucomatous loss

However, pattern deviation can underestimate disease in:

• Very advanced glaucoma
• Widespread diffuse glaucomatous damage
• Fields with minimal remaining normal sensitivity

Both total and pattern deviation should be reviewed.

Mean Deviation

Mean deviation, or MD, summarises how the overall field differs from age-adjusted normal sensitivity.

A value near zero is generally closer to the age-adjusted reference range.

A more negative value indicates greater overall depression.

MD may become more negative because of:

• Glaucoma
• Cataract
• Uncorrected refractive error
• Retinal disease
• Poor test performance

MD is useful for:

• Staging
• Trend analysis
• Monitoring global change

It does not describe the location of the defect.

Pattern Standard Deviation

Pattern standard deviation, or PSD, reflects irregularity within the field.

PSD may be elevated with localised defects.

In very advanced disease, PSD may fall again because the entire field becomes uniformly depressed.

A low PSD does not therefore guarantee a normal field.

Visual Field Index

The visual field index, or VFI, expresses function as a percentage.

It places greater weight on central locations.

A VFI close to 100% generally indicates a near-normal field.

Lower values indicate greater loss.

VFI is often used to:

• Display progression
• Estimate rate of decline
• Communicate disease severity

VFI may be less affected by cataract than MD, but it is not immune to artefact or measurement limitations.

Glaucoma Hemifield Test

The glaucoma hemifield test compares corresponding regions above and below the horizontal meridian.

Glaucoma commonly produces asymmetric damage across this meridian.

Possible classifications include:

• Within normal limits
• Borderline
• Outside normal limits
• General reduction of sensitivity
• Abnormally high sensitivity

The glaucoma hemifield test is a statistical classification, not an independent diagnosis.

Probability Symbols

Probability plots show how unusual each point is compared with the reference population.

For example, a symbol may indicate that fewer than:

• 5%
• 2%
• 1%
• 0.5%

of healthy reference eyes would be expected to have a result that low.

A statistically unusual point should be interpreted according to:

• Adjacent points
• Anatomical pattern
• Reproducibility
• OCT findings
• Clinical examination

Reliability Indices

Fixation Losses

Fixation losses estimate whether the patient maintained central fixation.

One method periodically presents stimuli in the expected blind spot.

A response may suggest that fixation shifted.

However, fixation-loss values may also be affected by:

• Incorrect blind-spot location
• Head movement
• Anatomical variation
• False-positive responses

Fixation loss should be considered alongside gaze tracking and the field pattern.

Gaze Tracking

Some perimeters continuously estimate eye movement.

A gaze-tracking graph may show:

• Upward spikes from fixation movement
• Downward markers for blinking or loss of pupil tracking

Gaze tracking provides useful information, but current evidence does not support reducing reliability to a single rigid gaze-tracking threshold. itive Responses

A false-positive response occurs when the patient presses despite no stimulus being presented or responds too quickly to be plausible.

High false-positive rates may cause:

• Artificially high sensitivity
• An unusually “white” field
• Underestimation of disease
• Scattered implausibly high thresholds
• An abnormally high-sensitivity message

False positives are among the most concerning reliability errors.

False-Negative Responses

A false-negative response occurs when the patient fails to respond to a brighter stimulus at a location where a dimmer stimulus was previously seen.

False negatives may increase because of:

• Fatigue
• Inattention
• Advanced glaucoma
• Fluctuating diseased sensitivity
• Slow reaction time

A high false-negative rate does not automatically mean that the patient was uncooperative.

It may reflect genuine disease variability.

Test Duration

An unusually long test may suggest:

• Advanced loss
• Poor understanding
• Variable responses
• Frequent pauses
• Fatigue
• An unsuitable strategy

Long testing can itself worsen reliability.

Reliability Cut-Offs

Traditional reports flag tests when preset percentages are exceeded.

These thresholds should not be applied blindly.

A test with an apparently acceptable reliability index may still be clinically unusable.

A test flagged as unreliable may still contain recognisable and reproducible information.

False-positive responses usually distort results more seriously than isolated fixation losses or false negatives. ing Effect

Visual field testing is a learned task.

A first-time patient may:

• Respond too slowly
• Search for stimuli
• Misunderstand faint lights
• Lose fixation
• Become anxious
• Tire quickly

The second test may appear better even though the eye has not changed.

Studies in previously inexperienced glaucoma patients found clinically meaningful improvement between the first and second tests, with smaller changes after further testing. first field is therefore commonly repeated before:

• Confirming glaucoma
• Declaring progression
• Making a major treatment decision

Common Visual Field Artefacts

Cloverleaf Artefact

A cloverleaf pattern occurs when the patient responds well at initial seed locations but loses attention later.

The field may show:

• Relatively preserved sensitivity near four starting areas
• Marked surrounding depression
• A clover-like appearance

It may indicate fatigue or poor sustained attention rather than true disease.

Lens-Rim Artefact

The edge of the trial lens may block peripheral stimuli.

This may produce:

• A curved peripheral defect
• Temporal or inferior depression
• An abrupt rim-like boundary

Correct head position and lens placement are important.

Uncorrected Refractive Error

Blur can cause diffuse reduction in sensitivity.

This is particularly important for:

• Higher prescriptions
• Astigmatism
• Central test programs
• Older patients needing near correction

Ptosis or Eyelid Artefact

A drooping upper eyelid may create a superior defect.

The field may improve when the lid is taped.

This comparison may be useful in functional ptosis assessment.

Eyelash Artefact

Long eyelashes or an incompletely elevated lid may produce:

• Superior depression
• Irregular shadowing
• Variable defects

Cataract

Cataract commonly causes:

• Generalised depression
• More negative mean deviation
• Reduced contrast sensitivity

A cataract may make glaucoma appear worse globally without creating the typical anatomical pattern of localised nerve-fibre loss.

Small Pupil

A very small pupil can reduce retinal illumination and produce diffuse sensitivity depression.

Dry Eye

An unstable tear film can cause:

• Fluctuating blur
• Reduced sensitivity
• Inconsistent responses
• Increased fatigue

Lubricating drops and blinking may improve performance.

Poor Fixation

Looking towards the flashes may shift defects or create inconsistent results.

The patient should continue looking at the central target.

Fatigue

Fatigue may cause:

• Slower responses
• Missed stimuli
• Increased variability
• A worsening field towards the end of the test

Shorter strategies or a rest between eyes may help.

Trigger-Happy Responses

Pressing whenever a flash is expected may cause:

• False positives
• Artificially good thresholds
• Unreliable progression analysis

Neurological or Motor Difficulty

Hand weakness, tremor, cognitive impairment or slow reaction time may affect button responses.

Alternative arrangements may include:

• Verbal responses
• Assistance with the response button
• Kinetic perimetry
• Larger stimuli
• Shorter strategies
• Objective testing in selected settings

Visual Field Testing in Glaucoma

Why Is It Essential?

OCT measures structure.

Visual field testing measures function.

Glaucoma can show:

• Structural loss before detectable field loss
• Field loss before definite OCT change
• Disagreement because of measurement variability
• Different progression rates in structure and function

Both tests are needed.

Common Early Glaucoma Defects

Possible early patterns include:

• Paracentral scotoma
• Nasal step
• Temporal wedge
• Small arcuate defect
• Localised depression near fixation

A 2024 systematic review confirmed that glaucomatous patterns are diverse and may occur centrally even in relatively early disease. p

A nasal step is an abrupt sensitivity difference across the horizontal meridian in the nasal field.

It reflects the anatomical arrangement of retinal nerve-fibre bundles.

Arcuate Defect

An arcuate defect follows the course of retinal nerve-fibre bundles.

It may extend:

• From the blind spot
• Above or below fixation
• Towards the nasal field

Superior retinal nerve-fibre damage produces an inferior field defect, and inferior retinal damage produces a superior field defect.

Paracentral Scotoma

A paracentral scotoma lies close to fixation.

It may affect:

• Reading
• Fine detail
• Driving
• Contrast
• Visual function despite a relatively good global MD

Paracentral damage is particularly important in:

• Normal-tension glaucoma
• Macular ganglion-cell loss
• Fixation-threatening disease

Advanced Glaucoma

Advanced patterns may include:

• Extensive arcuate loss
• Double arcuate defects
• A central island
• A temporal island
• Generalised severe depression
• Loss threatening fixation

In advanced glaucoma:

• Test variability increases.
• Conventional size III stimuli may reach a measurement floor.
• A 10-2 test may better monitor remaining central vision.
• A larger size V stimulus may be considered.
• Clinical decisions increasingly depend on central function and progression.

Does a Normal Visual Field Exclude Glaucoma?

No.

A patient may have:

• Ocular hypertension
• Pre-perimetric glaucoma
• Structural optic-nerve or OCT change
• Early disease below the test’s detection threshold
• A defect between sampled test points

Diagnosis should not rely on one normal field.

Does an Abnormal Visual Field Prove Glaucoma?

No.

Other causes include:

• Cataract
• Retinal disease
• Optic neuritis
• Ischaemic optic neuropathy
• Neurological disease
• Ptosis
• Poor reliability
• High myopia
• Artefact

The pattern must match the suspected diagnosis.

Visual Field Progression

Progression means that functional loss has worsened beyond expected test variability.

It may be assessed with:

• Event analysis
• Trend analysis
• Pointwise analysis
• Cluster analysis
• Mean deviation slope
• Visual field index slope
• Clinical review of serial fields

Event Analysis

Event analysis compares follow-up fields with baseline tests.

It asks whether particular points have worsened beyond expected test-retest variability.

Commercial guided progression analysis may label findings as:

• Possible progression
• Likely progression

A progression alert should be reviewed rather than accepted automatically.

The specificity of “likely progression” is generally higher than “possible progression”, but false alerts occur more often in patients with variable fields. lysis

Trend analysis estimates the rate of change over time.

It may report:

• Mean deviation change in dB per year
• VFI change per year
• Pointwise sensitivity change
• Sectoral change

Trend analysis helps determine not only whether the field is worsening, but how quickly.

Why the Rate Matters

A slowly changing field in an older patient may carry a different lifetime risk from the same field in a young patient losing sensitivity rapidly.

The treatment goal is not simply to classify progression.

It is to reduce the projected risk of meaningful visual disability during the patient’s lifetime.

Why Two Baseline Fields Are Often Used

Baseline variability affects every later comparison.

Two reliable baseline fields reduce the chance that:

• An unusually good field makes later fields appear worse
• An unusually poor field masks progression
• Learning effects distort the baseline

How Often Should Visual Fields Be Repeated?

The schedule depends on:

• Diagnosis
• Severity
• Risk factors
• Suspected rate of progression
• Treatment change
• Reliability
• Patient age
• Remaining visual reserve

More frequent early testing helps establish:

• A reliable baseline
• Test variability
• The likely rate of change

Simulation and longitudinal studies suggest that testing several times during the first two years can detect rapid progression earlier than annual testing. Once stability is established, testing may be spaced according to individual risk. ing Visual Fields

Frontloading means performing two short visual fields per eye during the same visit.

Potential advantages include:

• Immediate confirmation of a suspicious defect
• Faster familiarisation
• Better estimation of variability
• More data with relatively little extra time using SITA Faster

Large prospective studies found that the second SITA Faster field was often more reliable and that paired fields produced repeatable data at a modest time cost. may not be suitable for every patient, particularly when fatigue is substantial.

Central Progression and the 10-2 Test

A conventional 24-2 progression analysis may miss change concentrated in the macula.

One study found that some early glaucoma eyes with macular progression identified using combined OCT and central visual fields were not detected by 24-2 guided progression analysis. 2C should be considered when:

• OCT suggests central ganglion-cell progression
• A paracentral defect is present
• Fixation is threatened
• Symptoms are not explained by the 24-2
• The patient has selectively central disease

Visual Field Testing in Neurological Disease

Visual-field patterns may help localise disease along the visual pathway.

The field should be interpreted with:

• Visual acuity
• Colour vision
• Pupil responses
• Optic-disc appearance
• Neurological symptoms
• Brain or orbital imaging when indicated

Both 24-2 and 30-2 automated perimetry are widely used in neuro-ophthalmology, while kinetic testing remains important when peripheral or irregular defects require mapping. ve Disease

Optic neuropathy may produce:

• Central scotoma
• Centrocaecal scotoma
• Altitudinal loss
• Arcuate-like loss
• Diffuse depression

The pattern alone does not identify the cause.

Optic Neuritis

Optic neuritis may cause:

• Central sensitivity loss
• Diffuse depression
• Localised defects
• Reduced colour vision
• Pain with eye movement

The visual field can help document severity and recovery.

Ischaemic Optic Neuropathy

Ischaemic optic neuropathy commonly produces:

• Altitudinal loss
• Arcuate loss
• Central involvement
• Sectoral defects

An altitudinal defect is not exclusive to ischaemic disease.

Chiasmal Disease

Compression of the optic chiasm may cause:

• Bitemporal field loss
• Defects respecting the vertical meridian
• Superior temporal loss initially in some pituitary lesions
• Asymmetric defects

A suspicious bitemporal pattern requires clinical and neurological assessment.

Post-Chiasmal Disease

Disease behind the optic chiasm may cause a homonymous defect affecting the same side of the visual field in both eyes.

Examples include:

• Right homonymous hemianopia
• Left homonymous quadrantanopia

Causes may include:

• Stroke
• Tumour
• Trauma
• Inflammation
• Surgery

Sudden homonymous loss may indicate an acute neurological emergency.

Papilloedema

Raised intracranial pressure may produce:

• Enlarged blind spots
• Peripheral constriction
• Nasal defects
• Arcuate loss in chronic disease

Visual-field testing helps monitor function but does not replace investigation of the cause.

Visual Field Testing in Retinal Disease

Retinal Detachment

A retinal detachment may produce a defect corresponding to the detached retina.

Because retinal images are inverted, a superior retinal detachment may cause an inferior field defect.

A visual field is not the preferred test for excluding an acute retinal tear or detachment.

Urgent dilated examination is required for:

• New flashes
• A sudden shower of floaters
• A curtain or shadow
• Sudden peripheral loss

Retinitis Pigmentosa

Retinitis pigmentosa may cause:

• Ring scotomas
• Progressive mid-peripheral loss
• Tunnel vision
• Reduced night vision

Kinetic testing may be useful for mapping remaining peripheral islands.

Macular Disease

Macular disease may produce:

• Central scotoma
• Metamorphopsia
• Reduced central sensitivity

Microperimetry or a dense central field may provide more useful information than a broad glaucoma grid.

Retinal Vascular Disease

A retinal artery or vein occlusion may produce:

• Sectoral defects
• Altitudinal loss
• Central loss
• Generalised depression

The field pattern should be correlated with the visible retinal vascular territory.

Hydroxychloroquine Screening

Central automated fields may be used alongside retinal imaging.

The selected field pattern depends partly on retinal toxicity distribution.

Common approaches include:

• 10-2 testing for parafoveal disease
• Wider patterns in patients at risk of more peripheral pericentral involvement

Visual fields should be interpreted with OCT and other recommended retinal tests because false-positive results are possible.

Eyelid and Orbital Conditions

A drooping upper eyelid may obstruct the superior visual field.

Testing may be performed:

• With the eyelid in its natural position
• With the eyelid taped upwards

An improvement with taping may help document functional obstruction.

The result should be interpreted with:

• Eyelid measurements
• Photographs
• Symptoms
• Local regulatory or insurer criteria

Orbital disease may also produce visual-field loss through optic-nerve compression.

Binocular Visual Fields and Driving

Driving depends on more than high-contrast visual acuity.

Relevant visual functions include:

• Binocular visual field
• Contrast sensitivity
• Glare tolerance
• Attention
• Reaction time
• Eye movements
• Cognitive function

Glaucoma-related binocular field loss has been associated with difficulty detecting peripheral hazards and poorer driving performance in some studies. ual-field requirements vary by:

• Country
• Licence class
• Private or commercial driving
• Underlying diagnosis

A medical visual field should not be assumed to satisfy a licensing authority unless the required test and reporting format are used.

Visual Field Testing in Children

Children may perform automated perimetry when they can:

• Understand the task
• Maintain fixation
• Use the response button
• Remain seated

The test may be adapted using:

• Shorter programs
• Larger stimuli
• Kinetic perimetry
• Frequent encouragement
• Repeat testing

A poor first result may reflect age or unfamiliarity rather than disease.

Visual Field Testing in Older Adults

Testing may be affected by:

• Cataract
• Small pupils
• Dry eye
• Reduced concentration
• Neck or back discomfort
• Hearing or cognitive impairment
• Slower response time
• Tremor or hand weakness

Adaptations may include:

• Shorter algorithms
• Rest between eyes
• Larger targets
• Improved seating
• Repeating only clinically relevant sections

Advanced Visual Loss and Low Vision

Standard threshold algorithms may become unreliable when sensitivity is extremely low.

Possible alternatives include:

• Size V stimuli
• 10-2 testing
• Kinetic perimetry
• Esterman binocular testing
• Functional mobility assessment
• Low-vision evaluation

Can the Patient Cheat on a Visual Field Test?

Intentional over-response usually creates recognisable inconsistencies.

However, the test is not a lie detector.

Clinical interpretation should remain objective and may include:

• Repeat testing
• Alternative test strategies
• Comparison with OCT
• Binocular functional testing
• Kinetic fields
• Electrophysiology
• Neurological assessment

Can Visual Field Loss Improve?

A result may improve because of:

• Learning
• Better fixation
• Cataract surgery
• Corrected refractive error
• Improved ptosis
• Resolution of optic-disc swelling
• Recovery from optic neuritis
• Reduced retinal fluid
• Improved test reliability

Established glaucomatous optic-nerve damage does not normally regenerate.

An improved test after glaucoma treatment often reflects variability rather than restored nerve tissue.

Home and Portable Visual Field Testing

Tablet, web-based and virtual-reality perimeters are being developed for:

• Home monitoring
• Telemedicine
• Low-resource settings
• More frequent testing
• Patients unable to access a conventional perimeter easily

Pilot studies have shown that selected patients can perform repeated home fields with good adherence and clinically useful agreement with in-clinic testing. nalysis of Melbourne Rapid Fields found:

• Shorter testing than conventional Humphrey testing
• Good agreement in global indices
• Some systematic differences in MD and PSD
• Less favourable conventional reliability indices

Portable testing is promising, but it does not yet make all devices or results interchangeable with standard automated perimetry. also requires:

• Standardised screen brightness
• Correct viewing distance
• Appropriate refractive correction
• A controlled testing environment
• Reliable fixation
• Secure data transfer
• Clinical review

Objective Perimetry

Conventional perimetry requires a conscious button response.

Objective methods attempt to infer visual-field function from physiological signals such as:

• Pupillary responses
• Visual evoked potentials
• Eye movements
• Brain responses

These methods may help patients unable to perform conventional tests, but they are not routine replacements for standard automated perimetry in most glaucoma care.

Artificial Intelligence and Visual Fields

Artificial intelligence may assist with:

• Detecting artefacts
• Predicting future fields
• Estimating function from OCT
• Identifying progression
• Selecting test locations
• Reducing testing time
• Personalising monitoring frequency

Potential limitations include:

• Dependence on training data
• Device-specific bias
• Poor performance in unusual anatomy
• False reassurance
• Lack of clinical context

AI should support rather than replace clinical assessment.

Limitations of Visual Field Testing

Visual field testing is limited by:

• Subjective responses
• Learning effects
• Fatigue
• Test-retest variability
• Sparse spatial sampling
• Reaction-time differences
• Media opacity
• Refractive blur
• Fixation instability
• Algorithm-specific results
• Floor effects in advanced disease

The test measures sensitivity at selected points rather than continuously across every part of vision.

A small defect may fall between test locations.

Why Visual Field and OCT Results May Disagree

Possible reasons include:

• Structural loss before functional loss
• Functional loss before detectable structural change
• OCT segmentation errors
• Perimetry artefact
• High myopia
• Advanced OCT floor effect
• Advanced visual-field floor effect
• Different anatomical areas being assessed
• Normal biological variability

Disagreement should prompt review of:

• Raw OCT images
• Visual-field reliability
• Field pattern
• Previous tests
• Optic-disc examination
• Macular ganglion-cell maps

Common Myths

“Visual Field Testing Measures How Clearly I See”

False.

It measures where and how sensitively the patient sees while looking at a central target.

“I Should Press Whenever I Think a Light Might Appear”

False.

Press when a light is genuinely seen.

“Missing Lights Means I Performed Badly”

False.

The test deliberately presents lights that are too dim to detect.

“The First Visual Field Is Always Accurate”

False.

Learning effects are common.

“An Unreliable Test Is Completely Useless”

Not necessarily.

The ophthalmologist may still recognise a reproducible pattern, although important decisions generally require confirmation.

“A Reliable Test Is Definitely Correct”

False.

Artefacts may occur despite acceptable reliability percentages.

“A Red Point Means Glaucoma”

False.

It means that sensitivity is statistically lower than the reference range.

“A Normal Field Means I Cannot Have Glaucoma”

False.

Early or pre-perimetric glaucoma may have a normal field.

“Visual Field Loss Can Be Restored by Lowering Eye Pressure”

False.

Pressure control aims to prevent additional loss.

“OCT Has Replaced Visual Field Testing”

False.

OCT measures structure; perimetry measures function.

“A 24-2 Tests My Entire Peripheral Vision”

False.

It samples the central and near-peripheral field rather than the far peripheral extent.

“The 10-2 Is Only for Advanced Glaucoma”

False.

It may detect and monitor early paracentral damage.

“An Esterman Test Diagnoses Glaucoma”

False.

It assesses binocular functional field and is not a detailed diagnostic glaucoma threshold test.

“I Can Memorise the Flash Pattern”

False.

Stimulus order and brightness vary.

“Visual Field Testing Uses Radiation”

False.

The machine presents visible light.

Frequently Asked Questions

Why Do I Need a Visual Field Test?

Common reasons include:

• Glaucoma assessment
• Glaucoma monitoring
• Optic-nerve disease
• Neurological symptoms
• Retinal disease
• Ptosis
• Driving assessment
• Unexplained visual loss

Why Do I Need Another Test When the First Was Abnormal?

The abnormality may need confirmation because of:

• Learning effect
• Fatigue
• Artefact
• Fixation instability
• False-positive responses
• Cataract
• Refractive blur

Why Is My Second Test Better?

Possible reasons include:

• Greater familiarity
• Better concentration
• Improved positioning
• More appropriate refractive correction
• Less anxiety
• Natural test variability

Why Is My Visual Field Worse When My Vision Feels the Same?

Peripheral or paracentral loss may progress without obvious symptoms.

The other eye may compensate.

Small measured changes may also reflect variability and require confirmation.

Can I Close My Eyes to Rest?

Ask the operator to pause.

Closing the tested eye during active testing may cause missed stimuli and disrupt fixation.

Should I Press for Very Faint Lights?

Yes, when the light is genuinely perceived.

Do not wait until every light is bright and obvious.

Should I Look Towards the Flash?

No.

Continue looking at the central target.

What Happens if I Blink?

Normal blinking is expected.

A blink may cause one missed stimulus, which the algorithm can often retest.

What Happens if I Accidentally Press the Button?

An occasional accidental response is unlikely to invalidate the test.

Repeated guessing may cause a high false-positive rate.

Why Is One Eye Tested Before the Other?

The order may reflect:

• Clinic workflow
• The eye of greater concern
• Previous testing order
• The need to reduce fatigue in the more important eye

Should the Same Eye Always Be Tested First?

Consistency may help, but always testing one eye second could expose it to greater fatigue.

The test order may be adjusted when fatigue affects results.

Why Does the Machine Make Clicking Sounds When No Light Appears?

The machine and response button may make sounds unrelated to visible stimuli.

Do not use sound as a cue to respond.

What Does a Negative Mean Deviation Mean?

It indicates that the overall field is less sensitive than the age-adjusted reference level.

The number should be interpreted with the field pattern, cataract status and reliability.

What Does a VFI of 100% Mean?

It means the result is close to the device’s expected normal functional range.

It does not guarantee that the optic nerve is healthy.

What Does “Outside Normal Limits” Mean?

It means the statistical pattern is unusual compared with the reference population.

It does not identify the cause by itself.

Can Cataract Affect the Test?

Yes.

Cataract can create diffuse sensitivity depression and worsen global indices.

Can Dry Eye Affect the Test?

Yes.

Fluctuating blur and discomfort can reduce consistency.

Can High Myopia Affect the Test?

Yes.

High myopia may be associated with:

• Optic-disc abnormalities
• Retinal changes
• Glaucoma
• Non-glaucomatous field defects

The result should be correlated with OCT and retinal examination.

Can Migraine Affect the Visual Field?

A migraine aura can cause temporary visual phenomena.

Formal testing between episodes may be normal.

A persistent or atypical defect requires investigation for other causes.

Can Stroke Affect the Visual Field?

Yes.

Stroke may cause homonymous hemianopia or quadrantanopia.

A sudden visual-field defect requires urgent medical assessment.

Can a Brain Tumour Affect the Field?

Yes.

Tumours involving the optic nerves, chiasm or posterior visual pathways may cause characteristic defects.

Perimetry does not replace brain or orbital imaging.

Can Visual Fields Be Performed with One Eye Blind?

Yes.

The seeing eye can be assessed monocularly.

A binocular functional test may not provide additional information when one eye has no useful vision.

Can I Drive After a Routine Visual Field Test?

Yes, provided:

• The pupils were not dilated
• Vision is otherwise adequate
• No sedating medication was given

Passing a clinic field does not automatically confirm legal fitness to drive.

How Often Will I Need Testing?

The interval depends on:

• Diagnosis
• Glaucoma severity
• Stability
• Treatment changes
• Reliability
• Risk of progression

Some patients need several tests in the first year, followed by less frequent testing once a stable rate is established.

When to Seek Urgent Eye Care

A scheduled visual field test should not delay urgent assessment for:

• Sudden loss of vision
• A new curtain or shadow
• New flashes with a shower of floaters
• Sudden loss of one side of vision
• New double vision
• Severe eye pain
• A red eye with nausea or vomiting
• New weakness, facial droop or speech difficulty
• Sudden severe headache with visual symptoms
• Rapidly worsening central vision

These symptoms may indicate:

• Retinal tear or detachment
• Retinal vascular occlusion
• Acute angle closure
• Optic-nerve disease
• Stroke
• Another neurological emergency

A Visual Field Test Checklist

Before the Test

• Bring current spectacles.
• Use prescribed eye medication unless advised otherwise.
• Tell the operator if you have neck or back discomfort.
• Report dry eye or difficulty keeping the eye open.
• Ask for instructions if anything is unclear.
• Inform the operator if this is your first visual field.

During the Test

• Look only at the central target.
• Press when a light is genuinely seen.
• Do not worry about missed lights.
• Blink normally.
• Avoid guessing.
• Ask for a pause when needed.
• Keep the forehead and chin in position.

Information to Report

• Glaucoma
• Cataract
• Retinal disease
• Optic neuritis
• Stroke
• Brain tumour
• Pituitary disease
• Ptosis
• High myopia
• Previous eye surgery
• Neurological symptoms
• Medication that affects concentration

Questions to Ask the Ophthalmologist

• Which visual field program was used?
• Was the test reliable?
• Is there a learning effect?
• Is the defect reproducible?
• Does the pattern suggest glaucoma?
• Does it match my OCT?
• Is central vision threatened?
• Do I need a 10-2 or 24-2C test?
• Has the field progressed?
• What is my rate of change?
• Could cataract or ptosis affect the result?
• When should the field be repeated?
• Does the finding affect driving?
• What symptoms require urgent assessment?

The Bottom Line

A visual field test maps how sensitively a patient sees in different areas while looking straight ahead.

It is used to assess:

• Glaucoma
• Optic-nerve disease
• Neurological disease
• Retinal disease
• Eyelid obstruction
• Functional binocular vision

The most common clinical method is standard automated perimetry.

Frequently used programs include:

• 24-2 for general glaucoma assessment
• 24-2C for combined peripheral and enhanced central sampling
• 10-2 for detailed central-field assessment
• 30-2 for selected neurological and optic-nerve conditions
• Esterman testing for binocular functional assessment

The report may contain:

• Threshold values
• Grey-scale maps
• Total deviation
• Pattern deviation
• Mean deviation
• Pattern standard deviation
• Visual field index
• Glaucoma hemifield test
• Reliability indices
• Progression analysis

An abnormal field may result from:

• Glaucoma
• Retinal disease
• Optic-nerve disease
• Neurological disease
• Cataract
• Ptosis
• Refractive blur
• Poor fixation
• Fatigue
• False-positive responses
• Learning effects

A single field should rarely be interpreted in isolation.

Reliable diagnosis and monitoring depend on:

• Reproducible testing
• Review of the complete field pattern
• Comparison with previous tests
• Correlation with OCT and clinical findings
• An appropriate test grid
• Assessment of the rate of change

The most important message is:

Visual field testing is a functional test that depends on patient responses and naturally varies from one session to another. The computer’s summary numbers and warning labels are useful, but the true meaning comes from the pattern, reliability, reproducibility and relationship to the patient’s optic nerve, retina, symptoms and previous results.

References

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