This book is intended to serve as an introduction to clinical automated perimetry and particularly visual field testing using the Humphrey perimeter.
It has been written as a concise introduction and reference that may be used by busy practitioners and in training programs. Because of its purpose, this primer does not follow the outline of most textbooks. For example, the bare essentials of modern practical perimetry are covered in a very condensed form in Chapter 1. Chapter 2 has been written primarily with residents and optometry students in mind; it describes normal and abnormal visual fields and how visual field testing works.Those who only have time for absolutely basic information may choose just to read Chapter 1 and to refer to the other chapters as the need may arise. We do, however, strongly recommend that you also read Chapter 4. This chapter addresses what we believe to be the single most fertile area for improving clinical perimetry—the management and training of patients and technical staff.
Compared to the 4th edition, the 5th edition has 40% new content. What’s new in the Fifth Edition:
- Expanded material on perimetry basic principles
- Even more practical recommendations for using perimetry in glaucoma management
- Argumentation for more frequent visual field testing in glaucoma patients
- Latest perimetry guidance including SITA Faster
- Updated suggestions for patient education
- A new chapter on using software analysis to facilitate clinical decisions based on a combination of various test and observation data
- More than twice as many citations as the 4th edition
- The Essentials
- Review of Basic Principles
- Choosing a Test
- Patient-Friendly Perimetry
- STATPAC Analysis of Single Fields
- Assessing Perimetric Change
- Glaucomatous Visual Field Loss
- Data Integration and Presentation
- Perimetry in Glaucoma Management
- Neurological Visual Field Loss
- Visual Field Loss in Retinal Diseases
- Artifactual Test Results
- Perimeter Design
Writing this 5th edition of the Humphrey primer has reminded us of just how much visual field testing has evolved since the days when we wrote each of the previous editions. The first two editions introduced Humphrey perimetry itself (in 1986) and the internationally-based normative data application we called Statpac (in 1987). The 2002 third edition focused on the then-new SITA testing strategies and the fourth edition in 2012 emphasized the importance of careful patient management during testing. We also have realized that all four of these earlier editions were written primarily for the use of practicing ophthalmologists and optometrists, with little thought given to the needs of young trainees.
In this edition, we have sought to make the book more suitable for use in residency, and optometric training programs. Thus, we have expanded the basic principles section (Chapter 2) to briefly teach topics that we previously had assumed that our audience already understood. We have also expanded the chapter on the use of perimetry in glaucoma management (Chapter 9), providing increased emphasis on practical ways of using perimetric data to address common and important patient care questions. We hope that those additions will also help experienced eye professionals take better advantage of perimetric data in their management of patients with glaucoma.
A second area of emphasis comes from our recent work to further shorten testing times, which resulted in the introduction of the SITA Faster testing algorithm. We undertook this project in order to encourage and facilitate more frequent visual field testing in recently diagnosed glaucoma patients.
Our third point of emphasis is embodied in a new chapter (Chapter 8) covering the use of server-based analysis software in order to provide user access to the Humphrey Statpac and Glaucoma Progression Analysis applications on desktop computers. We believe that this software approach has truly come of age and, perhaps more importantly, also can now facilitate quick and effective patient care decisions by serving as asumming point for other clinical data, such as automated imaging results, clinical observations, surgical events and pharmaceutical regimens.
This fifth edition celebrates 38 years of collaboration between its three authors in the development of clinical perimetry. We wish to recognize and thank those who have helped us along the way, a list too long to be recorded here. We especially wish to recognize Professor Douglas R. Anderson, who has been our collaborator, mentor and friend for almost all of those years. We also wish to celebrate the memory of Professor Stephen M. Drance, who, during his long life helped us immeasurably.
We wish to thank those who have helped us with this new edition of the HFA Primer: Douglas R. Anderson, Sabina Andersson-Geimer, Anders Bergström, Dimitrios Bizios, Thomas Callan, Buck Cunningham, Thomas Fitzmorris, William Gustafson, Björn Hammar, Aiko Iwase, Eric Larson, Gary Lee, Christopher Leung Kai Shun, Georg Lindgren, Steven A. Newman, Marina Pekelis, Dorothea Peters, Catarina Villalba, Michael Wall, and Claudia Wasch. These colleagues have generously given us their best advice, and each of them has helped us improve this book in important ways. However, none of them has endorsed or approved what we have written.
Each of the authors serves as a perimetry consultant to Carl Zeiss Meditec, Incorporated. Zeiss has helped us publish this book, but has had no editorial control over the book’s contents. Thus, we, the authors bear complete responsibility for the contents of this work.
Anders Heijl, MD, PhD
Mike Patella, OD
Boel Bengtsson, PhD
Anders Heijl is Senior Professor and Consultant at the Dept of Ophthalmology, Skåne University Hospital Malmö, Lund University, Sweden, where he served as chairman between 1990 and 2012.
Prof. Heijl received a Ph.D. from the University of Lund in 1977 for his early work on computerized perimetry, and later completed a post-doctoral fellowship under the mentorship of Professor Stephen Drance at the University of British Columbia.
Prof. Heijl, Prof. Boel Bengtsson and their research group have invented and developed the Statpac programs for the Humphrey perimeter, including the now widely used concepts of Probability Maps, Pattern Deviation, Change Probability Maps, the Glaucoma Hemifield Test. The Swedish Interactive Thresholding Algorithm (SITA) was also developed in their laboratory, as was the Glaucoma Progression Analysis (GPA ) programmes and the VFI index. A new most efficient SITA test (SITA Faster) was recently released by the team after several years of testing.
Prof. Heijl initiated and has served as Study Director of the Early Manifest Glaucoma Trial (EMGT) and is medical director of the new Glaucoma Intensive Treatment Study (GITS).
Between 1980 and 1996 Anders Heijl served the International Perimetric Society first as Scientific Secretary and later as President. Between 2003 and 2008 he served as President of the Glaucoma Research Society. Dr Heijl is the past president of the Swedish Glaucoma Society and senior mentor of the European Glaucoma Society.
Prof. Heijl was the chief ophthalmological advisor to the Swedish National Board of Health and Welfare 2003-2012.
Prof. Heijl has published about 200 scientific papers, chapters and books and has scientific awards or delivered name lectures about 25 times. He has served as Editor-in-Chief and Co-Editor of Acta Ophthalmologica since 2000, and on the editorial boards of several ophthalmic journals.
Prof. Heijl is an Honorary Member of the International Perimetric Society, the Glaucoma Research Society, the Finnish Ophthalmological Society, The Swedish Ophthalmological Society and the South-African Glaucoma Society.
Dr. Mike Patella retired from Carl Zeiss Meditec in 2018 after 46 years, working as Director of Clinical Research, Director of the Glaucoma Business Unit, Director of New Business Development, and Vice President of Professional Affairs. He currently serves as a consultant to Carl Zeiss Meditec and other companies, and also as is an Adjunct Assistant Professor at the University of Iowa Department of Ophthalmology.
Dr. Patella holds degrees in physics from Pomona College, in meteorology from Texas A&M University, and in vision science from UC Berkeley, and also took his doctorate from the UC Berkeley School of Optometry.
Dr. Patella began his career as a US Air Force meteorology officer and after completing his military service worked as an aerospace engineer on NASA manned spaceflight projects. He left aerospace engineering in 1975 in order to become an optometrist, and concurrently joined a Berkeley startup called Humphrey Instruments, which had been founded that year by the Nobel Laureate, Luis W. Alvarez. Humphrey Instruments was later purchased by Zeiss and came to be known as Carl Zeiss Meditec.
Dr. Patella worked for more than four decades at Humphrey and Zeiss on the invention and development of automated ophthalmic diagnostic instruments, including automated refractors and lensometers, contact lens fitting devices, automated perimeters, and automated imaging systems, including the first clinical system for optical coherence tomography. He is named as an inventor in seven patents.
Dr. Patella and his HFA Primer co-authors, Professors Anders Heijl and Boel Bengtsson formed the nucleus of the international team that invented and developed the Humphrey perimeter, beginning in 1982 and continuing into the present. Together, the authors also have written five editions of the Humphrey Primer, which continues to be distributed worldwide and may be the most widely used textbook in all of ophthalmology and optometry.
Boel Bengtsson is a Professor at the Dept of Clinical Sciences in Malmö, Ophthalmology, Lund University, Sweden.
Before becoming a world recognized leader in clinical perimetry research, Boel Bengtsson started her career as a registered ophthalmic nurse, and B.Sc. with a major in statistics.
Together with Anders Heijl and the team researchers at the Lund University Boel Bengtsson headed development of the algorithms for perimetric threshold strategies. Her PhD research at University of Lund delivered the now famous Swedish Interactive Thresholding Algorithm (SITA). Boel Bengtsson was also a leading contributor in the development of Statpac programs for the Humphrey perimeter, the Glaucoma Progression Analysis (GPA ) and the VFI index.
The most recent addition to the clinical perimetry developed by Boel Bengtsson, Anders Heijl and their team was the SITA Faster test strategy that became a game changing innovation in the standard automated perimetry and was recently implemented in the HFA3 visual field instrument.
Prof. Bengtsson initiated Glaucoma Intensive Treatment Study (GITS) and now serves as a Study Director and a board member of the Swedish Glaucoma Society. Prof. Bengtsson published over 100 scientific papers, chapters and books. She now manages a research team at the Dept of Clinical Sciences, Ophthalmology, Lund University in Malmö.