Diagnostic ability of Humphrey perimetry, Octopus perimetry, and optical coherence tomography for glaucomatous optic neuropathy

Comparison of the visual field test of Glaufield Lite with Humphrey Field Analyser

PURPOSE

To compare visual field test results of Glaufield Lite AP901 CTS 133 (Appasamy Associates, Mannadipet Commune, Thirubhuvanai, Puducherry, India, hereafter Glaufield Lite) with Humphrey Field Analyser (HFA, Carl Zeiss Meditec, Dublin, California, USA, hereafter HFA).

METHODS

A pilot study at a tertiary eye centre involving 23 normal and 24 glaucoma patients who underwent two consecutive visual field tests on (i) HFA 24-2 SITA Fast and (ii) Glaufield Lite Quick Central program.

RESULTS

The mean testing time on HFA was significantly shorter than Glaufield Lite (normals: HFA: 2.75 ± 0.49 min, Glaufield Lite: 6.85 ± 0.86 min, p < 0.001; glaucoma patients: HFA: 3.45 ± 1.08 min, Glaufield Lite: 6.95 ± 0.54 min, p < 0.001). Reliability criteria were similar, but false-positivity was lower with Glaufield Lite. Bland-Altman analysis showed poor agreement for mean deviation (MD), [~ 2.69 units less for HFA], and acceptable agreement for pattern standard deviation (PSD) [~ 0.426 units more for HFA] between the two devices.

CONCLUSION

Both perimetric techniques showed reliable test results though test duration was longer with Glaufield Lite perimetry. The MD showed poor agreement, likely due to different scales and principles used for perimetry. The PSD showed acceptable agreement, making it valid for use in glaucoma, though a direct comparison of fields from the two devices is not possible. We recommend using the same perimetry device for follow-up evaluation.

Influence of implantation of diffractive trifocal intraocular lenses on standard automated perimetry

Background

This prospective comparative study aimed to investigate the influence of diffractive trifocal intraocular lenses (IOLs) implantation on standard automated perimetry.

Methods

Patients with no diseases affecting the visual field had undergone cataract surgery following the implantation of trifocal or monofocal IOLs from July 2019 to August 2020 were recruited. The normality of the anterior and posterior segments and absence of glaucomatous optic nerve cupping were confirmed preoperatively by slit-lamp examination. Standard automated perimetry was performed using Humphrey Visual Field 10–2 testing, 2–3 months after cataract surgery in only one eye per patient. The mean deviation (MD) and foveal sensitivity were compared between IOLs in eyes with acceptable reliability indices and best-corrected visual acuity of 20/25 or better.

Results

Among the 83 eyes of the 83 patients included, 39 and 29 eyes eligible for perimetry analysis had trifocal and monofocal IOLs, respectively. The mean MD and foveal sensitivity in eyes with trifocal IOLs were significantly lower than those in eyes with monofocal IOLs (P < 0.021), with mean differences of 0.77 and 1.01 dB, respectively.

Conclusion

The comparison in nonglaucomatous eyes demonstrated that the influence of trifocal IOLs on standard automated perimetry was greater than that of monofocal IOLs.

Infrared- and white-light retinal sensitivity in glaucomatous neuropathy

Glaucoma causes irreversible neuropathy, which, untreated, may lead to blindness. In this case-control study, we measured two-photon infrared (IR) light sensitivity in glaucomatous eyes to propose a new method to quantify the visual loss. In total, 64 patients were recruited with an equal distribution between glaucoma and control groups. Retinal sensitivity to IR light was assessed using a two-photon excitation device. A fundus-driven microperimeter was used to measure retinal sensitivity to visible light. The retinal nerve fiber layer (RNFL) thickness was quantified automatically with optical coherence tomography. The IR sensitivity of glaucoma and control eyes differed significantly (P = .003): 9.8 (6.5 to 13.1) dB vs. 10.9 (8.2 to 13.0) dB. Although in the visible-light microperimetry, retinal sensitivity was decreased in glaucoma (17.0, range: 6.9 to 20.0 dB) compared to the controls (17.7, range: 11.6 to 20.0 dB), this difference did not reach the significance level. A significant thinning of the RNFL in the glaucoma group was observed (P < .001). IR sensitivity significantly correlated with the RNFL in three of the four assessed quadrants instead of only one in visible-light microperimetry. Although further research is needed, this proof-of-concept study suggests that IR-light sensitivity can be used to support the detection of glaucomatous neuropathy.

Should clinical automated perimetry be considered for routine functional assessment of early/intermediate age-related macular degeneration (AMD)? A systematic review of current literature

Purpose

There is growing interest in functional testing for early/intermediate age‐related macular degeneration (iAMD). However, systematic evaluation of existing clinical functional tests is lacking. This systematic review examines evidence for using clinical automated perimetry in routine assessment of early/iAMD.

Recent findings

PubMed, Web of Science Core Collection, and Embase were searched from inception to October 2020 to answer, is there evidence of visual field defects in early/iAMD, and if so, are early/iAMD visual field defects linked to real‐world patient outcomes? Articles using clinical automated perimetry (commercially accessible and non‐modified devices/protocols) were included. Microperimetry was excluded as this has yet to be incorporated into clinical guidelines. The primary outcome was global visual field indices including mean deviation (MD), pattern standard deviation (PSD), mean sensitivity (MS) and frequency of defects. The secondary outcome was any real‐world patient outcome including quality of life and/or activities of daily living indices. Twenty‐six studies were eligible for inclusion and all studies were observational. There was consistent evidence of worsened MD, PSD, MS and frequency of defects for early/iAMD compared to normal eyes under photopic, low‐photopic and scotopic conditions. Meta‐analysis of studies using standard automated perimetry (SAP) under photopic conditions revealed worsened MD (−1.52dB [−2.27, −0.78 dB]) and MS (−1.47dB [−2, −0.94 dB]) in early/iAMD compared to normal eyes, representing large statistical effect sizes but non‐clinically meaningful reductions. There was insufficient data for meta‐analyses regarding other clinical automated perimetry protocols. Only one study assessed a real‐world patient outcome (on‐road driving performance), with no significant link to visual field outcomes in early/iAMD.

Summary

Significant reduction of global visual field indices is present in early/iAMD, but not clinically meaningful using SAP under photopic conditions. Translational relevance of visual field outcomes to patient outcomes in early/iAMD remains unclear. Thus, SAP under photopic conditions is unlikely to be useful for routine assessment of early/iAMD.

A Comparative Study between Swedish Interactive Thresholding Algorithm Faster and Swedish Interactive Thresholding Algorithm Standard in Glaucoma Patients

Purpose:

To compare the results of the new strategy Swedish Interactive Thresholding Algorithm (SITA) Faster to the results of SITA Standard in patients with glaucoma.

Methods:

This was a cross-sectional study of 49 patients with glaucoma and previous experience with standard automated perimetry. Two consecutive tests were performed in random order, one with SITA Standard and another one with SITA Faster, in the studied eye of each patient. Comparisons were made for test time, mean deviation (MD), visual field index (VFI), and number of depressed points in pattern deviation map and total deviation map for every level of significance.

Results:

The average test time was 56% shorter with SITA Faster (P < 0.001). The intraclass correlation coefficient (ICC) for MD and VFI showed excellent agreement between both strategies, ICC = 0.98 (95% confidence interval [CI]: 0.96, 0.99) and ICC = 0.97 (95% CI: 0.95, 0.99), respectively. For the number of depressed points in total deviation map and pattern deviation map, ICC demonstrated good agreement with values between 0.8 and 0.95.

Conclusions:

Our study shows that SITA Faster is a shorter test with strong agreement with SITA Standard parameters. These results suggest that SITA Faster could replace SITA Standard for glaucoma diagnosis.

Effects of glaucoma surgery on visual field progression in open-angle glaucoma considering the floor effect

Purpose

The aim of this retrospective analysis was to investigate whether trabeculectomy (TRAB) and XEN® Gel Stent implantation (XEN) – both filtrating surgery techniques – can slow down the deterioration of visual field (VF) parameters considering the floor effect, which could lead to a misestimation of pre‐ and postoperative VF rate of progression (ROP).

Methods

Included in this study were patients with open‐angle glaucoma, who underwent either TRAB or XEN® gel stent implantation and who had at least three VF tests before and after surgery, over an observation period of 13 years. The annual ROP of the mean defect (MD) and the square root of loss variance (sLV) were calculated with two different censoring thresholds: by censored regression and by ordinary least squares regression (OLSR). In addition, the diagnostic range of sLV was calculated.

Results

48 eyes of 39 glaucoma patients were included in the study. The annual rate of MD progression was significantly reduced by filtering surgery when calculating the yearly ROP using OLSR (p = 0.006) and by censoring values exceeding a precalculated cut‐off of 14.20 dB (p = 0.041) and a cut‐off from the literature of 15.00 dB (p = 0.028). On average, the MD was impacted by a significant floor effect of 14.20 dB (95% CI: 12.83‐15.56), corresponding to 17.7/59 absolute defects or 29.9% of the whole VF. When applying both OLSR and censored regression, the annual rate of sLV progression did not show a significant difference. The sLV showed a diagnostic boundary at a MD of 15.78 dB.

Conclusion

This study shows that filtering surgery can reduce the progression of VF in patients with open‐angle glaucoma, especially those whose disease develops aggressively. This is valid even if the floor effect in advanced cases is compensated by censored regression. On average, the ROP of MD is affected by a significant floor effect at about 29.9% absolute loss of the whole VF.

Deep Relation Transformer for Diagnosing Glaucoma With Optical Coherence Tomography and Visual Field Function

Glaucoma is the leading reason for irreversible blindness. Early detection and timely treatment of glaucoma are essential for preventing visual field loss or even blindness. In clinical practice, Optical Coherence Tomography (OCT) and Visual Field (VF) exams are two widely-used and complementary techniques for diagnosing glaucoma. OCT provides quantitative measurements of the optic nerve head (ONH) structure, while VF test is the functional assessment of peripheral vision. In this paper, we propose a Deep Relation Transformer (DRT) to perform glaucoma diagnosis with OCT and VF information combined. A novel deep reasoning mechanism is proposed to explore implicit pairwise relations between OCT and VF information in global and regional manners. With the pairwise relations, a carefully-designed deep transformer mechanism is developed to enhance the representation with complementary information for each modal. Based on reasoning and transformer mechanisms, three successive modules are designed to extract and collect valuable information for glaucoma diagnosis, the global relation module, the guided regional relation module, and the interaction transformer module, namely. Moreover, we build a large dataset, namely ZOC-OCT&VF dataset, which includes 1395 OCT-VF pairs for developing and evaluating our DRT. We conduct extensive experiments to validate the effectiveness of the proposed method. Experimental results show that our method achieves 88.3% accuracy and outperforms the existing single-modal approaches with a large margin. The codes and dataset will be publicly available in the future.

The Future Is Now: Incorporating Telemedicine into Glaucoma Care

Purpose of Review

The field of teleglaucoma has expanded rapidly in recent years with several large-scale teleglaucoma screening programs in existence throughout the world. Additionally, teleglaucoma programs for use in disease management are under study. The limited access to care that resulted from the COVID-19 pandemic highlighted the need for expansion of such programs. This article reviews the literature on teleglaucoma for screening and management of glaucoma, discussing considerations for incorporating teleglaucoma into clinical practice.

Recent Findings

Teleglaucoma screening reduces the rate of false-positive referrals and can accurately screen at-risk populations with accuracy similar to in-person screening. The use of teleglaucoma for the management of glaucoma shows promise for low-risk patients with early disease. Furthermore, teleglaucoma is cost-effective and reduces travel burden for patients resulting in high patient satisfaction.

Summary

Teleglaucoma offers potential for improving access to glaucoma care, reducing the burden on patients and health care systems.

Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition

Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.

Telemedicine for Glaucoma: Guidelines and Recommendations

Background: Glaucoma is the leading cause of irreversible blindness worldwide. Access to glaucoma specialists is challenging and likely to become more difficult as the population ages. Introduction: Using telemedicine for glaucoma (teleglaucoma) has the potential to increase access to glaucoma care by improving efficiency and decreasing the need for long-distance travel for patients. Results: Teleglaucoma programs can be used for screening, diagnostic consultation, and long-term treatment monitoring. Key components of teleglaucoma programs include patient history, equipment, intraocular pressure measurement, pachymetry, anterior chamber imaging/gonioscopy, fundus photography, retinal nerve fiber layer imaging, medical record and imaging software, and skilled personnel. Discussion: Teleglaucoma has tremendous potential to improve patient access to high-quality cost-effective glaucoma care. Conclusions: We have reviewed some special considerations needed to address the complexity of providing guideline-concordant glaucoma care.

Validation and reproducibility of the Heidelberg Edge Perimeter in the detection of glaucomatous visual field defects

AIM

To validate the ability of the Heidelberg Edge Perimeter (HEP) in detecting glaucomatous visual field (VF) defects compared to the Octopus Visual Field (OVF) Analyzer and to determine the test-retest repeatability of both modalities.

METHODS

This prospective, cross-sectional study was conducted at Wills Eye Hospital, Philadelphia, PA. Glaucoma subjects and unaffected controls underwent VF testing using HEP standard automated perimetry (SAP) III 30-2 Adaptive Staircase Thresholding Algorithm (ASTA) FAST protocol and OVF G-TOP white-on-white strategy. Testing order was randomized. Pearson's correlation coefficient was calculated for both mean deviation (MD) and pattern standard deviation/square root of loss of variance (PSD/sLV). Receiver operating characteristic (ROC) curves were used to determine the diagnostic abilities of both modalities. Glaucoma subjects returned for repeat testing and intraclass correlation coefficients (ICCs) were calculated to assess test-retest repeatability.

RESULTS

Seventy-nine subjects with glaucoma and 36 unaffected controls were enrolled. HEP and OVF were significantly correlated for both MD (r=-0.84; P<0.01) and PSD/sLV (r=0.79; P<0.01). Areas under the ROC curves (AUCs) were also comparable between HEP and OVF for both MD (0.74 and 0.79, respectively; P=0.26) and PSD/sLV (0.74 and 0.82; P=0.08). ICC was high for both HEP (0.96 for MD, 0.95 for PSD/sLV) and OVF (0.82 and 0.88, respectively). Mean test duration (min) was significantly shorter for OVF (2.63) compared to HEP (5.15; P<0.01).

CONCLUSION

HEP and OVF show strong correlation for both MD and PSD/sLV, and have similar validity for detecting glaucoma. The test-retest repeatability is high for both HEP and OVF, however the average testing duration of HEP is significantly longer than that of OVF.

Optical coherence tomography for glaucoma diagnosis: An evidence based meta-analysis

Purpose

Early detection, monitoring and understanding of changes in the retina are central to the diagnosis of glaucomatous optic neuropathy, and vital to reduce visual loss from this progressive condition. The main objective of this investigation was to compare glaucoma diagnostic accuracy of commercially available optical coherence tomography (OCT) devices (Zeiss Stratus, Zeiss Cirrus, Heidelberg Spectralis and Optovue RTVue, and Topcon 3D-OCT).

Patients

16,104 glaucomatous and 11,543 normal eyes reported in 150 studies.

Methods

Between Jan. 2017 and Feb 2017, MEDLINE^®, EMBASE^®, CINAHL^®, Cochrane Library^®, Web of Science^®, and BIOSIS^® were searched for studies assessing glaucoma diagnostic accuracy of the aforementioned OCT devices. Meta-analysis was performed pooling area under the receiver operating characteristic curve (AUROC) estimates for all devices, stratified by OCT type (RNFL, macula), and area imaged.

Results

150 studies with 16,104 glaucomatous and 11,543 normal control eyes were included. Key findings: AUROC of glaucoma diagnosis for RNFL average for all glaucoma patients was 0.897 (0.887–0.906, n = 16,782 patient eyes), for macula ganglion cell complex (GCC) was 0.885 (0.869–0.901, n = 4841 eyes), for macula ganglion cell inner plexiform layer (GCIPL) was 0.858 (0.835–0.880, n = 4211 eyes), and for total macular thickness was 0.795 (0.754–0.834, n = 1063 eyes).

Conclusion

The classification capability was similar across all 5 OCT devices. More diagnostically favorable AUROCs were demonstrated in patients with increased glaucoma severity. Diagnostic accuracy of RNFL and segmented macular regions (GCIPL, GCC) scans were similar and higher than total macular thickness. This study provides a synthesis of contemporary evidence with features of robust inclusion criteria and large sample size. These findings may provide guidance to clinicians when navigating this rapidly evolving diagnostic area characterized by numerous options.