Comparison of Humphrey Field Analyzer and imo visual field test results in patients with glaucoma and pseudo-fixation loss

Prospective Comparison of VisuALL Virtual Reality Perimetry and Humphrey Automated Perimetry in Glaucoma

Aim and background

Automated perimetry plays an important role in the diagnosis and monitoring of glaucoma patients. The purpose of this study is to prospectively determine parity between Humphrey visual field analyzer (HVFA) perimetry (the current gold standard) and the VisuALL virtual reality perimeter (VRP).

Materials and methods

In this prospective fully paired diagnostic accuracy study, patients with stable, long-term HVFA visual fields (horizontal dots for ≥4 consecutive visits on progression analysis) with preperimetric, mild, moderate, or severe visual field loss were familiarized with the VRP and then tested using its proprietary software. These results were used for point-by-point comparison with a contemporaneous HVFA test. This study was approved by the Institutional Review Board (IRB) of the University of the Incarnate Word, San Antonio, Texas, United States of America (IRB approval #20-06-002).

Results

The prospective study analyzed 43 eyes of 24 glaucoma patients. Spearman's correlation of mean deviation (MD) revealed a strong correlation between HVFA and VRP with rs(41) = 0.871, p < 0.001. The overall mean difference in locus-locus sensitivity between the devices was -0.4 ± 1.5 dB but varied for different visual field locations and glaucoma severity.

Conclusion

The parity between the VRP and HVFA was remarkably strong for mild and moderate glaucoma. Given its portability, ease of use, space efficiency, and low cost, the VRP presents a viable alternative.

Clinical significance

Automated perimetry, specifically the HVFA, has been the gold standard for visual field assessment since its introduction. The recent COVID-19 pandemic has illuminated the advantages of the VRP, allowing for safer visual assessment for both patient and clinician alike. Our study hopes to establish parity between these systems, allowing for the efficient integration of a novel head-mounted perimetry system that can safely diagnose and monitor glaucomatous progression in clinical practice.

Precis

Investigation of parity between Olleyes VisuALL virtual reality perimetry (VRP) and existing standard HVFA perimetry is essential to the diagnosis and management of glaucoma. Linear correlations between the two were established from 43 glaucomatous eyes. Parity was strong for mild and moderate glaucoma, presenting VRP as a viable alternative.

How to cite this article

Griffin JM, Slagle GT, Vu TA, et al. Prospective Comparison of VisuALL Virtual Reality Perimetry and Humphrey Automated Perimetry in Glaucoma. J Curr Glaucoma Pract 2024;18(1):4-9.

Comparison of the TEMPO binocular perimeter and Humphrey field analyzer

This study compared between TEMPO, a new binocular perimeter, with the Humphrey Field Analyzer (HFA). Patients were tested with both TEMPO 24-2 Ambient Interactive Zippy Estimated by Sequential Testing (AIZE)-Rapid and HFA 24-2 Swedish Interactive Threshold Algorithm (SITA)-Fast in a randomized sequence on the same day. Using a mixed-effects model, visual field (VF) parameters and reliability indices were compared. Retinal nerve fiber layer (RNFL) thickness was measured using Cirrus optical coherence tomography (OCT), and coefficient of determinations for VF and OCT parameters were calculated and compared using Akaike information criteria. 740 eyes (including 68 healthy, 262 glaucoma suspects, and 410 glaucoma) of 370 participants were evaluated. No significant differences were seen in mean deviation and visual field index between the two perimeters (P > 0.05). A stronger association between VF mean sensitivity (dB or 1/L) and circumpapillary RNFL was found for TEMPO (adjusted R2 = 0.25; Akaike information criteria [AIC] = 5235.5 for dB, and adjusted R2 = 0.29; AIC = 5200.8 for 1/L, respectively) compared to HFA (adjusted R2 = 0.22; AIC = 5263.9 for dB, and adjusted R2 = 0.22; AIC = 5262.7 for 1/L, respectively). Measurement time was faster for TEMPO compared to HFA (261 s vs. 429 s, P < 0.001). Further investigations are needed to assess the long-term monitoring potential of this binocular VF test.

Participant Experience Using Novel Perimetry Tests to Monitor Glaucoma Progression

PRCIS

Participant surveys taken after using tablet-based and smart visual function analyzer (SVFA) perimetry tests suggest that patients may prefer novel perimetry tests over traditional visual field machines.

PURPOSE

Compare patient experience using the IMOvifa SVFA and the tablet-based Melbourne Rapid Fields visual field (VF) tests to the Humphrey Field 24-2 Swedish Interactive Threshold Algorithm Standard.

PATIENTS AND METHODS

Prospective observational cohort study on adult participants with diagnoses of glaucoma suspect, ocular hypertension, or glaucoma. Participants attended 2 study visits ~3 months apart. During the first visit, participants were trained to use the 2 novel perimeters, took 1 test on both new devices and the Humphrey Field Analyzer, then were surveyed. Participants received tablets and performed weekly tablet VF tests at home between study visits. At the final study visit, participants re-took the VF tests and completed the same surveys.

RESULTS

Eighty-one participants were surveyed twice. At the baseline survey, participants preferred the SVFA (71.7%) and tablet tests (69.2%) over the Humphrey VF. Most were willing to perform weekly monitoring at home on the SVFA (69.1%) and tablet (75.4%). Participants generally had a "very good" overall experience when testing on the SVFA (71.6%) and tablet (90.1%). At the final visit, fewer participants were willing to test on the tablet daily (23.5% to 9.9%; P = 0.02 for change) and more were willing to test monthly (18.5% to 33.3%; P = 0.03 for change).

CONCLUSION

Users reported a preference for novel VF devices. Overall participant experience using these devices was positive, supporting the feasibility of home monitoring of VFs from an experience perspective.

Test-retest repeatability of the imo binocular random single-eye test and Humphrey monocular test in patients with glaucoma

PURPOSE

To evaluate the reproducibility of the imo binocular random single-eye test (BRSET) and Humphrey Field Analyzer (HFA) monocular test in patients with glaucoma.

STUDY DESIGN

Retrospective observational study.

METHODS

We measured the visual fields (VF) of patients with glaucoma using the BRSET and HFA. All tests were repeated two months later. Mean sensitivity (MS), mean deviation (MD), sensitivity at each test location, and reliability indices were compared between the test days. Wilcoxon signed-rank test, interclass correlation coefficient (ICC), correlation coefficients, and Bland-Altman plots were generated for analysis.

RESULTS

We analyzed the VFs of 46 patients with glaucoma. There were no test-retest differences for MS and MD, and ICCs were > 0.9 for MS and MD in both perimeters. Inter-test correlations for MS and MD were high. The limits of agreement (LoAs) (lower, upper limit) between test days for MS were (- 3.4, 4.0) for BRSET and (-3.3, 3.0) for HFA. The LoA for MD was (- 3.3, 3.8) for BRSET and (- 3.2, 2.9) for HFA. Sensitivity at each testing location was more variable between testing days for BRSET than for HFA. For reliability indices, LoAs between testing days were wider for BRSET than for HFA.

CONCLUSION

The imo BRSET showed similar reproducibility to HFA in MS and MD. However, sensitivity at each test location varied more for BRSET than for HFA. Further studies are needed to verify the reproducibility of the imo BRSET.

Comparison of Perimetric Outcomes from a Tablet Perimeter, Smart Visual Function Analyzer, and Humphrey Field Analyzer

PURPOSE

The tablet-based Melbourne Rapid Fields (MRF) visual field (VF) test and the IMOvifa Smart Visual Function Analyzer (SVFA) are portable perimeters that may allow for at-home monitoring and more frequent testing. We compared tablet and SVFA results with outputs from the Humphrey Field Analyzer (HFA) 24-2 Swedish Interactive Threshold Algorithm Standard program.

DESIGN

Observational cross-sectional study.

SUBJECTS

Adult participants with a diagnosis of glaucoma, suspected glaucoma, or ocular hypertension seen in the Massachusetts Eye and Ear glaucoma clinic were enrolled. All participants were reliable and experienced HFA testers.

METHODS

Participants were tested with the SVFA and HFA. The study staff also trained participants on the MRF tablet with instructions to take weekly tests at home for 3 months. Visual field results from the 3 devices were compared.

MAIN OUTCOME MEASURES

Mean deviation (MD), pattern standard deviation (PSD), reliability parameters, and point sensitivity.

RESULTS

Overall, 79 participants (133 eyes) with a mean age of 61 ± 13 years (range, 26-79 years) were included; 59% of the participants were female, and the mean HFA MD was -2.7 ± 3.9 dB. The global indices of MD and PSD did not significantly vary between HFA and the 2 novel devices, except that the tablet VF reported a 0.6 dB higher PSD compared with HFA. However, tablet and SVFA sensitivities significantly differed from those of the HFA at 36 and 39 locations, respectively, out of 52 locations. Relative to HFA, the tablet overestimated light sensitivity in the nasal field while underestimating the temporal field. The SVFA generally underestimated light sensitivity, but its results were more similar to HFA results compared with the tablet.

CONCLUSIONS

Although average MD values from the 2 novel devices suggest that they provide similar results to the HFA, point-by-point comparisons highlight notable deviations. Differences in specific point sensitivity values were significant, especially between the tablet and the other 2 devices. These differences may in part be explained by differences in the devices' normative databases as well as how MD is calculated. However, the tablet had substantial differences based on location, indicating that the tablet design itself may be responsible for differences in local sensitivities.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Comparison of the TEMPO Binocular Perimeter and Humphrey Field Analyzer

This study compared between TEMPO, a new binocular perimeter, with the Humphrey Field Analyzer (HFA). Patients were tested with both TEMPO 24 - 2 AIZE-Rapid and HFA 24 - 2 SITA-Fast in a randomized sequence on the same day. Using a mixed-effects model, visual field (VF) parameters and reliability indices were compared. Retinal nerve fiber layer (RNFL) thickness was measured using Cirrus OCT, and coefficient of determinations for visual field and OCT parameters were calculated and compared using Akaike information criteria. 740 eyes (including 68 healthy, 262 glaucoma suspects, and 410 glaucoma) of 370 participants were evaluated. No significant differences were seen in mean deviation and visual field index between the two perimeters (P > 0.05). A stronger association between VF mean deviation and circumpapillary RNFL was found for TEMPO (adjusted R2 = 0.28; AIC = 5210.9) compared to HFA (adjusted R2 = 0.26; AIC = 5232.0). TEMPO had better reliability indices (fixation loss, false positive, and false negative) compared to HFA (all P < 0.05). Measurement time was faster for TEMPO compared to HFA (261sec vs. 429sec, P < 0.001). Further investigations are needed to assess the long-term monitoring potential of this binocular VF test.

Comparison of Visual Field Test Measurements With a Novel Approach on a Wearable Headset to Standard Automated Perimetry

PRCIS

This study of inter-test comparability of a novel visual field application installed on an augmented-reality portable headset and Humphrey field analyzer Swedish interactive thresholding algorithm (SITA) Standard visual field test demonstrates the excellent correlation of mean deviation (MD) and mean sensitivity (MS).

PURPOSE

To determine the correlation between visual field testing with novel software on a wearable headset versus standard automated perimetry.

PATIENTS AND METHODS

Patients with and without visual field defects attributable to glaucoma had visual field testing in one eye of each patient with 2 methods: re:Imagine Strategy (Heru, Inc.) and the Humphrey field analyzer (Carl Zeiss Meditec, Inc.) SITA Standard 24-2 program. Main outcome measures included MS and MD, which were evaluated by linear regression, intraclass correlation coefficient (ICC), and Bland Altman analysis for assessment of the mean difference and limits of agreement.

RESULTS

Measurements from 89 eyes of 89 patients (18 normal and 71 glaucomas) were compared with both instruments. Linear regression analysis demonstrated an excellent Pearson correlation coefficient of r = 0.94 for MS and r = 0.95 for MD. ICC analysis demonstrated high levels of concordance (ICC = 0.95, P < 0.001 for MS and ICC = 0.94, P < 0.001 for MD). Bland-Altman analysis determined a small mean difference between the two devices (Heru minus Humphrey) of 1.15 dB for MS and 1.06 dB for MD.

CONCLUSIONS

The Heru visual field test correlated well with SITA Standard in a population of normal eyes and eyes with glaucoma.

Perimetric Comparison Between the IMOvifa and Humphrey Field Analyzer

PRCIS

IMO visual function analyzer (IMOvifa), a binocular perimeter, has similar output to the Humphrey Field Analyzer (HFA), but reduced the measurement time.

PURPOSE

The purpose of this study is to evaluate the performance of IMOvifa, a perimeter that performs binocular visual field (VF) testing, and to compare its results with standard automated perimetry.

METHODS

All patients underwent HFA 24-2 SITA-Fast and IMOvifa 24-2 AIZE-Rapid on the same day. Mean deviation (MD), pattern SD (PSD), foveal threshold, and visual field index (VFI) were compared between the 2 perimeters using Wilcoxon signed-rank tests, Pearson correlation, and Bland-Altman plot. Measurement time for performing VF for both eyes was also collected for each device.

RESULTS

In this cross-sectional study, 138 eyes (including 25 healthy, 48 glaucoma suspects, and 65 primary open angle glaucoma) of 69 patients were evaluated. Measurement time was significantly faster for IMOvifa compared with HFA (256 vs. 419 s, P <0.001). No significant differences were seen in MD and VFI between HFA and IMOvifa (both P >0.05). Significant differences were seen in mean PSD 3.2 (2.7, 3.6) dB for HFA versus 4.1 (3.5, 4.6) for IMOvifa ( P <0.001), and foveal threshold 33.9 (33.1, 34.6) dB for HFA versus 30.6 (29.3, 31.9) dB for IMOvifa ( P <0.001). Pearson r was strong for MD ( r =0.90, P <0.001), PSD ( r =0.78, P <0.001), and VFI ( r =0.94, P <0.001). The mean difference (95% limits of agreement) was -0.1 (-3.8, 3.5) dB for MD, -0.4 (-3.4, 2.5) dB for PSD, and 0.1 (-8.9, 9.1) dB for VFI, respectively.

CONCLUSIONS

IMOvifa reduced measurement time by 39%. MD, PSD, and VFI values for IMOvifa showed good agreement with HFA SITA-Fast strategy. This perimeter reduced fatigue for both patient and examiner. Additional studies are needed to determine whether it will be useful for routine VF testing.

Agreement in the detection of chiasmal and postchiasmal visual field defects between imo binocular random single-eye test and Humphrey monocular test

PURPOSE

To compare the ability of imo binocular random single-eye test (BRSET) to detect visual field (VF) defects due to chiasmal and postchiasmal lesions (C/PCLs) with a Humphrey Field Analyzer (HFA) monocular test.

STUDY DESIGN

Prospective multicenter study METHODS: This study enrolled 40 patients with C/PCLs and measured their VFs using both imo BRSET and HFA monocular test. The VFs were classified into three groups using the cluster criterion: 1) bitemporal group, 2) homonymous group, and 3) others. The agreement and correlation of VF results between imo and HFA were analyzed using the Bland-Altman plot and Spearman correlation coefficient.

RESULTS

The VFs of 34 patients were analyzed and classified. There were 13 patients in the bitemporal, 6 in the homonymous, and 15 in the others group. BRSET showed a significantly shorter test duration than HFA. The imo systematically yielded a lower sensitivity than HFA. The average sensitivity at each test location correlated well between the perimeters in all groups, with the correlation coefficients ranging from 0.89 to 0.98. Bland-Altman plots showed wider limits of agreement in the affected quadrants compared to the unaffected quadrants in the bitemporal and homonymous groups. The fixation loss rate did not differ between the perimeters, but there were significant differences in the false positive and false negative rates between perimeters.

CONCLUSION

BRSET detected VF defects due to C/PCLs as accurately as the HFA monocular test with a shorter test duration.

Remote Video Monitoring of Simultaneous Visual Field Testing

PRCIS

In this prospective interventional case series that included 474 patients, there were no significant differences in visual field (VF) parameters between fields from patients tested one-at-a-time and simultaneously, except for fixation losses.

PURPOSE

To test for differences in reliability and performance parameters of patients taking VF tests while using a remote patient monitoring system to supervise 1 or 2 test sessions simultaneously.

METHODS

In a prospective interventional case series, 861 eyes of 474 consecutive patients undergoing automated perimetry during a 6-month period were monitored during the test using an audio/video-enabled remote monitoring system. Two patients were simultaneously tested (simultaneous test) by a single technician if they were ready for testing at the same time. Patients were otherwise tested individually (single test). Performance and reliability parameters including false negatives, false positives, fixation losses, mean deviation, pattern standard deviation, VF index, and test duration were compared between patients undergoing simultaneous tests and single tests. Patients undergoing remotely monitored testing, for whom a prior VF could be found, had performance and reliability parameters compared with those prior tests. VFs were analyzed separately for 2 test strategies: SITA Standard 24-2 and SITA Faster 24-2C.

RESULTS

No significant parameter differences were observed among SITA Standard 24-2 VFs between single and simultaneous tests, except for fixation losses (single: 16.8±19.7%, simultaneous: 22.5±25.0%, P=0.01). Similarly, there were no significant differences observed among SITA Faster 24-2C tests. Paired analyses comparing remotely monitored VFs with prior traditionally monitored VFs showed no significant differences for any parameters, except for fewer fixation losses with remote monitoring (traditional: 23.6±27.5%, remote 17.7±20.8%, P=0.003).

CONCLUSIONS

Remote patient monitoring of VF testing enabled technicians to supervise testing of 2 patients simultaneously with preserved performance and reliability.

Faster algorithms to measure visual field using the variational Bayes linear regression model in glaucoma: comparison with SITA-Fast

AIMS

To compare the visual field (VF) test results measured with the Swedish Interactive Threshold Algorithm Fast (SITA-Fast) and newly developed variational Bayes linear regression visual field (VBLR-VF) Fast or VBLR-VF Fast+.

METHOD

Of 65 patients with glaucoma, 31 eyes of 31 patients performed VBLR-VF Fast and SITA-Fast, and 34 eyes of 34 patients performed VBLR-VF Fast+ and SITA-Fast on the same day and iterated the same procedures within 6 months using the 24-2 test grid in the current prospective study. Global index (mean deviation and pattern SD), pointwise retinal sensitivity, test duration and reliability index (fixation loss, false positive and false negative) were compared between SITA-Fast and VBLR-VF Fast or VBLR-VF Fast+.

RESULTS

Global indices were not significantly different between SITA-Fast and VBLR-VF Fast or VBLR-VF Fast+. There was no significant difference in the pointwise retinal sensitivity between the SITA-Fast and VBLR-VF Fast algorithms at the first visit, while the VBLR-VF Fast algorithm was approximately 1 dB higher compared to the SITA-Fast algorithm at the second visit. Test duration was reduced by approximately 30 s (10%) with VBLR-VF Fast and by approximately 80 s (30%) with VBLR-VF Fast+ compared with to SITA-Fast (p<0.05). Most cases showed good reliability index values; however, a marginal but significant difference was observed between the VBLR-VF and SITA-Fast algorithms.

CONCLUSION

Both VBLR-VF Fast and VBLR-VF Fast+ considerably reduced the test durations. Although there was a marginal difference in the pointwise retinal sensitivities, global indices were almost interchangeable between the VBLR-VF Fast and SITA-Fast.

Comparison of imo and Humphrey field analyzer perimeters in glaucomatous eyes

AIM

To compare the imo perimeter, a new portable head-mounted perimeter unit that enables both eyes to be examined quickly and simultaneously, with the Humphrey field analyzer (HFA) perimeter to investigate correlations and their diagnostic ability in glaucomatous eyes.

METHODS

The performance of the equipment in 128 glaucomatous eyes and 40 normal eyes were tested. We investigated the correlations of mean deviation, pattern standard deviation, visual field index, and the sensitivity.

RESULTS

Measurements of mean deviation (r=0.886, P<0.001), pattern standard deviation (r=0.814, P<0.001), and visual field index (r=0.871, P<0.001) in both perimeters were strongly and positively correlated. The sensitivities in the imo perimeter were 80.5% for mean deviation, 81.2% for pattern standard deviation, and 80.5% in visual field index; those in the HFA were 63.3% for mean deviation, 74.5% for pattern standard deviation, and 80.5% for visual field index. Both perimeters demonstrated high diagnostic ability.

CONCLUSION

The parameters by the imo and HFA in glaucomatous eyes show strong positive correlations with favorable sensitivity, specificity, and diagnostic ability. However, the difference between imo and HFA results increases with the increase in visual field disturbance.

Measures of disease activity in glaucoma

Glaucoma is the leading cause of irreversible blindness globally which significantly affects the quality of life and has a substantial economic impact. Effective detective methods are necessary to identify glaucoma as early as possible. Regular eye examinations are important for detecting the disease early and preventing deterioration of vision and quality of life. Current methods of measuring disease activity are powerful in describing the functional and structural changes in glaucomatous eyes. However, there is still a need for a novel tool to detect glaucoma earlier and more accurately. Tear fluid biomarker analysis and new imaging technology provide novel surrogate endpoints of glaucoma. Artificial intelligence is a post-diagnostic tool that can analyse ophthalmic test results. A detail review of currently used clinical tests in glaucoma include intraocular pressure test, visual field test and optical coherence tomography are presented. The advanced technologies for glaucoma measurement which can identify specific disease characteristics, as well as the mechanism, performance and future perspectives of these devices are highlighted. Applications of AI in diagnosis and prediction in glaucoma are mentioned. With the development in imaging tools, sensor technologies and artificial intelligence, diagnostic evaluation of glaucoma must assess more variables to facilitate earlier diagnosis and management in the future.

Home Monitoring for Glaucoma: Current Applications and Future Directions

Technological advances provide a number of options for glaucoma monitoring outside the office setting, including home-based tonometry and perimetry. This has the potential to revolutionize management of this chronic disease, improve access to care, and enhance patient engagement. Here, we provide an overview of existing technologies for home-based glaucoma monitoring. We also discuss areas for future research and the potential applications of these technologies to telemedicine, which has been brought to the forefront during the ongoing COVID-19 pandemic.