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Visual field testing by confrontation not accurate

Clinical Question:
How reliable is the clinical assessment of visual fields?

Bottom Line:
When performed by neuro-ophthalmology fellows, clinical assessment of visual fields is not very accurate as compared with automated perimetry. (LOE = 2b)

Reference:
Kerr NM, Chew SS, Eady EK, Gamble GD, Danesh-Meyer HV. Diagnostic accuracy of confrontation visual field tests. Neurology 2010;74(15):1184-1190.  [PMID:20385890]

Study Design:
Cross-sectional

Funding:
Unknown/not stated

Setting:
Outpatient (specialty)

Synopsis:
These researchers evaluated 172 consecutive patients from neuro-ophthalmology clinics. Each patient underwent visual field testing by automated static perimetry (the big white hood with the flashing lights) and by bedside confrontation tests. Two neuro-ophthalmology fellows independently performed 7 different confrontation tests on each patient without knowing the results of the gold standard automated perimetry. The interobserver agreement for the clinical tests ranged from 0.6 to 0.8 (fair to good agreement). Not surprisingly, the clinical tests didn't perform very well individually. The overall sensitivity ranged from 25% to 77% and the specificity from 27% to 100% (negative likelihood ratio [LR-] range = 0.28 - 0.87; positive likelihood ratio [LR+] range = 1 - > 20. In other words, none of the clinical tests were reliable enough to rule out a visual field deficit, but if one is detected clinically (facial distortion, finger counting, wiggling fingers), it is often truly present. The combination of clinical tests that performed best was a static finger wiggle test with a kinetic 5-mm red target test (78% sensitive, 90% specific; LR+ = 8; LR- = 0.2). To perform the static finger wiggle test, one index finger of each outstretched arm is held in various peripheral positions and wiggled. The patient is asked to report which one wiggled. In the kinetic red target test, a 5-mm red-topped pin is moved inward from various peripheral positions and the patient asked when the pin is first perceived to be red. The authors don't report how well this works in patients with red-green color blindness.

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