Baseline 24-2 Central Visual Field Damage Is Predictive of Global Progressive Field Loss

Progressive Macular Vessel Density Loss and Visual Field Progression in Open-angle Glaucoma Eyes with Central Visual Field Damage

PURPOSE

To investigate the association between the longitudinal changes in both macular vessel density (mVD) and macular ganglion cell-inner plexiform layer thickness (mGCIPLT) and visual field (VF) progression (including central VF progression) in open-angle glaucoma (OAG) patients with central visual field (CVF) damage at different glaucoma stages.

DESIGN

Retrospective longitudinal study.

PARTICIPANTS

This study enrolled 223 OAG eyes with CVF loss at baseline classified as early-to-moderate (133 eyes) or advanced (90 eyes) stage based on the VF mean deviation (MD) (-10 dB).

METHODS

Serial mVDs at parafoveal and perifoveal sectors and mGCIPLT measurements were obtained using OCT angiography and OCT during a mean follow-up of 3.5 years. Visual field progression was determined using both the event- and trend-based analyses during follow-up.

MAIN OUTCOME MEASURES

Linear mixed-effects models were used to compare the rates of change in each parameter between VF progressors and nonprogressors. Logistic regression analyses were performed to determine the risk factors for VF progression.

RESULTS

In early-to-moderate stage, progressors showed significantly faster rates of change in the mGCIPLT (-1.02 vs. -0.47 μm/year), parafoveal (-1.12 vs. -0.40%/year), and perifoveal mVDs (-0.83 vs. -0.44%/year) than nonprogressors (all P < 0.05). In advanced stage cases, only the rates of change in mVDs (parafoveal: -1.47 vs. -0.44%/year; perifoveal: -1.04 vs. -0.27%/year; all P < 0.05) showed significant differences between the groups. By multivariable logistic regression analyses, the faster rate of mVD loss was a predictor of VF progression regardless of glaucoma stage, while the rate of mGCIPLT loss was significantly associated with VF progression only in early-to-moderate stage cases.

CONCLUSIONS

Progressive mVD loss is significantly associated with VF progression (including central VF progression) in the OAG eyes with CVF loss regardless of the glaucoma stage.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Predicting 60-4 visual field tests using 3D facial reconstruction

BACKGROUND

Despite, the potential clinical utility of 60-4 visual fields, they are not frequently used in clinical practice partly, due to the purported impact of facial contour on field defects. The purpose of this study was to design and test an artificial intelligence-driven platform to predict facial structure-dependent visual field defects on 60-4 visual field tests.

METHODS

Subjects with no ocular pathology were included. Participants were subject to optical coherence tomography, 60-4 Swedish interactive thresholding algorithm visual field tests and photography. The predicted visual field was compared with observed 60-4 visual field results in subjects. Average and point-specific sensitivity, specificity, precision, negative predictive value, accuracy, and F1-scores were primary outcome measures.

RESULTS

30 healthy were enrolled. Three-dimensional facial reconstruction using a convolution neural network (CNN) was able to predict facial contour-dependent 60-4 visual field defects in 30 subjects without ocular pathology. Overall model accuracy was 97%±3% and 96%±3% and the F1-score, dependent on precision and sensitivity, was 58%±19% and 55%±15% for the right eye and left eye, respectively. Spatial-dependent model performance was observed with increased sensitivity and precision within the far inferior nasal field reflected by an average F1-score of 76%±20% and 70%±29% for the right eye and left eye, respectively.

CONCLUSIONS

This pilot study reports the development of a CNN-enhanced platform capable of predicting 60-4 visual field defects in healthy controls based on facial contour. Further study with this platform may enhance understanding of the influence of facial contour on 60-4 visual field testing.

Foveal avascular zone vessel density is associated with visual field progression in early-stage glaucoma eyes with central visual field damage

We investigated the relationship between foveal avascular zone (FAZ)-related parameters, assessed by optical coherence tomography angiography (OCT-A), and visual field (VF) progression in early-stage open-angle glaucoma (OAG) eyes with central visual field (CVF) defects. Early-stage glaucoma eyes [VF mean deviation (MD) ≥ - 6 dB] with CVF defects were included. The rates of longitudinal change in FAZ-related parameters and structural parameters were evaluated and compared between VF progressors and non-progressors, using linear mixed effects models. Cox proportional hazards model and linear regression models were used to identify factors associated with VF progression, the VF MD reduction rate and the change rate of mean total deviation in central 12 VF points (MTD10). A total of 131 eyes were included and VF progression was detected in 32 eyes (24.4%) during 3.45 years of follow-up. The rates of reduction in vessel density in the 300 µm width annular region surrounding the FAZ (FD300) and macular ganglion cell-inner plexiform layer thickness (mGCIPLT) were significantly faster in progressors than in non-progressors. The faster VF MD or MTD10 reduction rates were associated with faster rates of FD300 loss and mGCIPLT reduction. The FD300 reduction rate is significantly associated with VF progression in early-stage OAG eyes with CVF defects. FD300 may be an adjunctive biomarker of VF progression in glaucomatous eyes with CVF defects.

Choroidal Microvasculature Dropout in Glaucoma

Glaucoma is a group of diseases characterized by distinctive visual field defect and optic nerve atrophy usually associated with elevated intraocular pressure (IOP). It is one of the most serious visual disorders and the leading cause of irreversible blindness worldwide. As a multifactorial disease, the pathogenesis of glaucoma is complicated and has been far from fully understood, where vascular factors are recognized to play an important role in its development and progression of glaucoma. Empirical researches have shown that parapapillary choroidal microvasculature dropout (CMvD) is closely associated with the impairment of optic nerve head (ONH) perfusion, probably accelerating the progression of glaucoma. Accordingly, it is necessary to explore the details regarding the relationship between CMvD and glaucoma progress, hoping to enhance the understanding of pathogenesis of glaucoma. In this review, we aimed to establish comprehensive understanding of the relationship between CMvD and glaucoma with generally going through relevant up-to-date literatures. Among the events that are closely associated with CMvD, we summarized the ones specifically involved in the term of glaucomatous pathological process, including thickness of retinal nerve fiber layer (RNFL) thickness, lamina cribrosa (LC) morphology, cricumpapillary vessel density (cpVD) and visual function such as visual field (VF) defect as well as the prognosis of glaucoma. Although researchers have made great advances, there are still many issues need to be addressed particularly concerning the pathogenic role of CMvD in glaucoma development and its clinical implications with respect to glaucoma prognosis.

Relationships of Macular Functional Impairment With Structural and Vascular Changes According to Glaucoma Severity

Purpose

To determine the pointwise relationships of central visual field (VF) defects with macular ganglion cell loss and macular vessel density (VD) loss during various stages of glaucoma.

Methods

Eyes with primary open-angle glaucoma (POAG) were subjected to optical coherence tomography (OCT) and OCT angiography (OCTA) to evaluate macular ganglion cell layer (GCL) thickness and macular VD in the superficial and deep vascular complexes (SVC and DVC). OCT, OCTA, and VF locations were matched after correcting for retinal ganglion cell (RGC) displacement. Pointwise correlations of GCL thickness and VDs of the SVC and DVC with central VF sensitivity (VFS) were evaluated by Pearson's correlation analysis and compared in eyes with early and advanced POAG by Meng's test.

Results

Of the 100 eyes, 52 and 48 were classified as early and advanced POAG. Macular VD showed overall better correlation with central VFS than GCL thickness in both the early and advanced groups. SVC density showed the strongest correlation with central VFS in all groups (R = 0.327 in early group, R = 0.325 in advanced group, all P < 0.001). Although DVC density showed better correlation with VFS (R = 0.311) than GCL thickness (R = 0.212) in the early group (P < 0.001), the correlation was comparable in the advanced group (R = 0.199 and 0.176, respectively, P = 0.254).

Conclusions

After adjustment for RGC displacement, macular SVC density was better correlated with central VFS than macular GCL thickness in both early and advanced POAG. Macular DVC density showed better correlation with VFS than GCL thickness in early but not in advanced POAG, indicating that DVC loss may be involved in early central VF loss.

Comparing Static Perimetry Protocols of Central Field Testing among Patients with Glaucoma

SIGNIFICANCE

On comparing the Humphrey Field Analyzer (HFA) 24-2C Faster, which tests 10 additional points in the central field, with the 24-2 Swedish Interactive Thresholding Algorithm (SITA) Standard for detecting central field defects, we found that the HFA 24-2C Faster may be used for the initial field evaluation in glaucoma with the advantage of a shorter testing time.

PURPOSE

This study aimed to compare the HFA 24-2C Faster with the 24-2 SITA Standard and 10-2 among patients with glaucoma for the number of defective central points, global indices, and testing time.

METHODS

Sixty eyes of 60 patients with glaucoma and glaucomatous visual field defects on the 24-2 SITA Standard algorithm underwent the 24-2C Faster and 10-2 field tests. The number of central points detected, global indices, and reliability indices were compared between the 24-2C Faster and the 24-2 SITA Standard and 10-2 field tests.

RESULTS

The 24-2C Faster, on average, detected 5.5 defective points more on the total deviation plot and 2 defective points more on the pattern deviation plot than the 24-2 SITA Standard in central 10°. The 10-2 algorithm detected 2.5 times more points on the total deviation plot than the 24-2C Faster. There was excellent consistency by an intraclass correlation coefficient of 0.95 for the mean deviation and 0.93 for the pattern standard deviation between the 24-2C Faster and the 24-2 SITA Standard. There was good consistency by an intraclass correlation coefficient of 0.80 for both mean deviation and pattern standard deviation between the 24-2C Faster and the 10-2. The testing time was significantly lower with the 24-2C Faster compared with the 24-2 SITA Standard and 10-2 test.

CONCLUSIONS

Our study demonstrates that the HFA 24-2C Faster may be used for the initial evaluation of the visual field in glaucoma with the added advantage of a shorter testing time compared with the 24-2 SITA Standard program.

Association of superficial macular vessel density with visual field progression in open-angle glaucoma with central visual field damage

Identifying the clinical relevance of superficial versus deep layer macular vessel density (mVD) in glaucoma is important for monitoring glaucoma patients. Our current retrospective longitudinal study investigated the association of superficial and deep layer mVD parameters with glaucomatous visual field (VF) progression in mild to moderate open-angle glaucoma (OAG) eyes with central visual field (CVF) damage. Serial optical coherence tomography (OCT) angiography-derived mVD measurements were obtained in 182 mild to moderate OAG eyes (mean deviation ≥ -10 decibels). Forty-eight eyes (26.4%) showed VF progression during a mean follow-up of 3.5 years. The parafoveal and perifoveal mVDs of both superficial and deep layers showed significantly faster reduction rates in the VF progressors than in the non-progressors according to linear mixed effects models (P < 0.05). Cox and linear regression analyses showed that greater reduction rates of both the superficial layer parafoveal and perifoveal mVDs, but not their deep layer counterparts, were significant predictors of VF progression and faster VF loss (P < 0.05). In conclusion, faster rates of change in superficial but not deep layer mVD parameters are significantly associated with subsequent VF progression and faster VF deterioration in mild to moderate OAG eyes with CVF damage.

Fast Progressors in Glaucoma: Prevalence Based on Global and Central Visual Field Loss

PURPOSE

To determine the prevalence of fast global and central visual field (VF) progression in individuals with glaucoma under routine care.

DESIGN

Observational study.

PARTICIPANTS

Six hundred ninety-three eyes of 461 individuals with glaucoma followed up over a median of 4.5 years.

METHODS

This study included (1) patients at a private ophthalmology clinic in Melbourne, Australia, and (2) individuals in 2 prospective longitudinal observational studies across 3 sites in the United States. All individuals had a diagnosis of glaucoma and were under routine care, and had performed 5 or more reliable 24-2 VF tests over a 1- to 5-year period. Ordinary least squares regression analyses were used to calculate the rate of global mean deviation (MD) change over time and the rate of the mean total deviation values of the 12 test locations within the central 10° region (MTD10) for each eye.

MAIN OUTCOME MEASURES

Prevalence of progression based on the rate of MD and the MTD10 change across various fixed cutoffs and cutoffs based on the estimated normal distribution (from the positive slopes).

RESULTS

Based on the MD and the MTD10, 12.5% and 11.7% of the eyes, respectively, exhibited a rate of change that was less than -1.0 dB/year (being a rate that typically is defined as "fast progression" for MD values), and 29.0% of the eyes showed a change of less than -0.5 dB/year on MTD10. Furthermore, 12.7% and 9.1% of the eyes exhibited a rate of change that exceeded the 1% cutoff of the estimated normal distribution MD and the MTD10 values, respectively.

CONCLUSIONS

This study found that approximately 1 in 8 eyes with glaucoma receiving routine care showed fast progression based on global MD values (< -1.0 dB/year) and that nearly 1 in 3 eyes showed a < -0.5 dB/year decline centrally. These findings highlight the clinical importance of assessing progressive central VF loss and reinforce the need for new therapies to prevent functional disability in a notable proportion of individuals who continue to exhibit fast progression.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Baseline 10-2 Visual Field Loss as a Predictor for Future Glaucoma Progression

PRCIS

Presence of baseline 10-2 visual field (VF) loss was the strongest predictor of future rate of 24-2 VF loss and development of new 24-2 progression events, suggesting a role for 10-2 VF testing in baseline glaucoma risk analysis.

PURPOSE

The purpose of this study is to examine the relationship between baseline 10-2 VF loss and future 24-2 VF loss.

MATERIALS AND METHODS

Subjects were participating in a prospective longitudinal study within a VA Medical Center outpatient eye clinic. Eligibility required 2 good quality baseline 10-2 VF tests followed by a minimum of 5 good quality 24-2 VF tests over at least 3 years. Longitudinal 24-2 VF testing was completed every 4-6 months after baseline 10-2 testing. Mixed model regression analyses and Cox Proportional Hazard regression analyses were completed to identify predictors of 24-2 mean deviation change rate and new VF loss events.

RESULTS

We studied 394 eyes of 202 subjects (119 primary open angle glaucoma and 83 glaucoma suspect). Over 6.7 (±1.5) years, 9.9 (±2.3) good quality 24-2 VF tests were completed. In mixed model regression analyses, baseline variables that predicted faster rate of 24-2 VF loss in order of strength of association were presence of baseline 10-2 VF defect, lower 24-2 mean deviation, and higher age. When analyses were completed without 10-2 variables, predictive capability of the model was reduced compared with when 10-2 variables were included. In Cox Proportional Regression analyses evaluating progression events, baseline 10-2 VF defect demonstrated the largest hazard ratio (22 times greater risk for developing future VF loss event in eyes with vs. without baseline 10-2 VF loss).

CONCLUSIONS

Baseline 10-2 VF defect was the most effective predictor of subsequent 24-2 VF progression in this study. These findings imply that presence of baseline 10-2 VF loss may provide unique value for predicting future glaucoma progression.

Longitudinal Structure-Function Relationship between Macular Vessel Density and Thickness and Central Visual Field in Early Glaucoma

PURPOSE

To investigate the relationship of longitudinal changes in macular vessel density (VD) from OCT angiography and in ganglion cell complex (GCC) from OCT with central visual field (VF) in eyes with early glaucoma.

DESIGN

Observational cohort.

PARTICIPANTS

A total of 95 eyes, 37 preperimetric and 58 with early glaucoma (24-2 VF mean deviation [MD] ≥ -6 decibels), with an average follow-up of 3.8 years and 5.3 visits, were included.

METHODS

Whole-image VD (wiVD) and whole-image GCC (wiGCC) and parafoveal scans, as well as localized regions of interest (LROIs), hemiretinae of whole images, and superior, inferior, temporal, and nasal sectors of parafoveal maps, were matched with central VF locations. Age-adjusted rates of change of VD, GCC, mean sensitivity of VF locations, and 10-2 VF MD were calculated using linear mixed-effect models. Normalized rates of change were calculated for comparison of change rates in wiVD and wiGCC.

MAIN OUTCOME MEASURES

Structure-function (SF) correlations of VD and GCC with central VF measurement change rates and comparison of different correlations of SF relationships after bootstrapping the difference of the correlation coefficients.

RESULTS

Vessel density loss and GCC thinning demonstrated significant correlations with central VF damage, globally and with most LROIs. The SF correlation (r, 95% confidence interval [CI]) between wiVD and 10-2 VF MD change rates was 0.42 [0.24, 0.58], whereas it was 0.27 [0.08, 0.45] between wiGCC and 10-2 VF MD changes rates (all P < 0.05). In contrast to GCC thinning, VD loss in the parafoveal sectors demonstrated significant correlations with central VF damage in inferior and temporal sectors. Differences in the relationship of SF with central VF damage were not significant between VD loss and GCC thinning. The mean (95% CI) normalized change rates of wiVD (-7.40 [-7.71 to 7.09] %/year) was faster than that of wiGCC (-2.39 [-2.94 to 1.84] %/year) (P < 0.05).

CONCLUSIONS

Rates of VD loss and GCC thinning are associated with central VF loss over time. Assessment of both macular VD and GCC thickness should be considered for evaluation of glaucoma progression.

Prediction of Central Visual Field Severity in Glaucoma

PRCIS

The severity of central visual field (VF) defects on 24-2 VF and related scotomas on 10-2 VF may be predicted by assessing perimetric defects at abnormal central 12 points on 24-2 VF in early glaucoma.

PURPOSE

Investigating the association between perimetric parameters at abnormal central 12 points on 24-2 VF and the severity of central visual field defects (CVFDs) on 24-2 VF and related parafoveal scotomas on 10-2 VF.

METHODS

We examined 64 eyes of 56 glaucoma patients with CVFDs on 24-2 VF with a mean deviation better than -7 dB and completed 24-2 and 10-2 VF testing within 6 months. On the basis of 10-2 VFs' pattern defects, eyes were grouped into 3: an arcuate parafoveal scotoma, severe defect; partial arcuate, moderate defect; and minimal defect. VF parameters at abnormal points (P<1%) within the central-most 4 and paracentral 8 points on total deviation/pattern deviation plots on 24-2 VF were analyzed to predict the severity of CVFDs.

RESULTS

Eyes with arcuate scotoma showed more functional loss than eyes without arcuate scotoma on 10-2 VF (P<0.001). A significant association was observed between abnormal 24-2 VF points' (<1%) threshold sensitivity lower than 20 dB [odds ratio (OR)=7.2; P=0.002 and OR=5.1; P=0.003 for the central 4 and paracentral 8 points, respectively] and defect values worse than -15 dB (OR=8.0 and 5.6 for the central 4 and paracentral 8 points, respectively, P=0.005) with arcuate scotoma on 10-2 VF. Superior nasal defect in the central 5 degrees on 24-2 VF was significantly associated with an arcuate defect on 10-2 VF (P<0.001).

CONCLUSION

Clinicians may predict the severity of CVFDs on 24-2 VF and parafoveal scotomas on 10-2 VF by measuring threshold sensitivities and defect values at abnormal central 12 points (<1%) on 24-2 VF in early glaucoma.

Baseline Vessel Density Parameters for Predicting Visual Field Progression in Open-Angle Glaucoma Eyes With Central Visual Field Damage

PURPOSE

To identify the baseline vessel density (VD) parameters that predict visual field (VF) progression in patients with open-angle glaucoma (OAG) with central visual field (CVF) damage.

DESIGN

Retrospective cohort study.

METHODS

This study enrolled 208 eyes from 208 consecutive patients with OAG with CVF damage at baseline and with a minimum 2 years of follow-up. Optical coherence tomography (OCT) angiography was used to measure circumpapillary and macular VDs in the retina and parapapillary VD in the choroid (pCVD) at the baseline. The circumpapillary retinal nerve fiber layer (cpRNFL) and macular ganglion cell-inner plexiform layer (mGCIPL) thicknesses were also measured as reference standards. Cox proportional hazard analysis was performed to identify the baseline clinical factors associated with VF progression according to the glaucoma stage. The relationships between the CVF mean sensitivity reduction rate during follow-up and the baseline clinical factors were evaluated.

RESULTS

VF progression was detected in 54 eyes (26.0%) during 2.78 years of mean follow-up. A lower pCVD (hazard ratio = 0.916, P = .014) at baseline in early-stage OAG eyes and a reduced baseline average mGCIPL thickness (hazard ratio = 0.896, P = .001) in eyes with moderate to advanced glaucoma were independent predictors of VF progression. The baseline pCVD (β = 0.018, P = .028) in eyes with early-stage glaucoma and the baseline average mGCIPL thickness (β = 0.035, P = .013) in eyes with moderate to advanced glaucoma were significantly correlated with the rate (dB/y) of CVF mean sensitivity reduction.

CONCLUSION

In eyes with OAG with CVF damage, a lower baseline pCVD in early-stage glaucoma and a reduced mGCIPL thickness at baseline in moderate to advanced glaucoma are significantly associated with subsequent VF progression.

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.

Investigation of progression pattern and associated risk factors in glaucoma patients with initial paracentral scotomas using Humphrey 10-2

Central visual field (VF) progression could directly threaten patientss visual function compared to glaucomatous damage. This study was designed to investigate visual field (VF) progression pattern and associated risk factors including optical coherence topography angiographic (OCT-A) findings in glaucoma patients with initial paracentral scotoma. This prospective, observational study included 122 eyes presenting as initial paracentral scotomas with serial 24-2 and 10-2 VF tests at the glaucoma clinic of Seoul St Mary's Hospital between November 2017 and August 2020. The participants underwent at least 5 serial VF exams and OCT-A at baseline. Numerical values of the initial and final 10-2 VF tests were averaged for each VF test point using the total deviation map. Innermost 10-2 VF progression was defined as three or more new contiguous points at the central 12 points on 10-2 VF. Other clinical characteristics were collected including history of disc hemorrhage and vessel density (VD) was measured from OCT-A images. Linear regression analysis was performed to obtain the change of mean deviation and a cut-off for progression was defined for both 24-2 and 10-2 VFs. The average total deviation maps of the initial 10-2 VF tests shows initial paracentral scotoma located in the superior region in an arcuate pattern that was deep in the 4°–6° region above fixation. This arcuate pattern was more broadly located in the 4°–10° region in the primary open-angle glaucoma (POAG) group, while it was closer to fixation in 0°–4° region in the normal-tension glaucoma (NTG) group. The final average map shows deepening of scotomas in the 4°–10° region in POAG, which deepened closer to the region of fixation in NTG. The diagnosis of NTG (β 1.892; 95% CI 1.225–2.516; P = 0.035) and lower choroidal VD in the peripapillary atrophy (PPA) region (β 0.985; 95% CI 0.975 to 0.995; P = 0.022) were significantly related to innermost 10-2 VF progression. Initial paracentral scotomas in NTG tended to progress closer to the region of fixation, which should be monitored closely. Important progression risk factors related to paracentral scotoma near the fixation were the diagnosis of NTG and reduced choroidal VD in the β-zone PPA region using OCT-A. We should consider vascular risk factors in NTG patients presenting with initial paracentral scotoma to avoid vision threatening progression of glaucoma.

Prediction of 10-2 Visual Field Loss Using Optical Coherence Tomography and 24-2 Visual Field Data

PRECIS

Using standard glaucoma structural and functional tests, clinicians accurately predicted the presence/absence of 10-2 glaucomatous visual field (VF) loss in 90% of the eyes in this study.

PURPOSE

To investigate how well clinicians with variable experience can predict the presence and location of 10-2 VF loss using structural and functional data that are routinely obtained for glaucoma assessment.

METHODS

Within a test set of 416 eyes (210 subjects) who were diagnosed glaucoma suspect or primary open-angle glaucoma (with most eyes having mild disease), 6 clinicians were asked to predict the presence and hemispheric location of 10-2 VF loss using 24-2 VF and spectral-domain optical coherence tomography structural data. Prediction accuracies were calculated for each clinician and compared using the weighted κ-statistic. Receiver operating characteristic analyses were used to evaluate models for predicting 10-2 VF loss.

RESULTS

Among the 6 clinicians, mean (range) accuracy, false negatives, and false positives for predicting presence/absence of 10-2 VF loss were 90% (87% to 92%), 4.7% (2.4% to 7.0%), and 5.4% (1.7% to 7.5%) respectively. The mean (range) weighted κ-statistic was 0.75 (0.64 to 0.83), suggesting good or very good inter-rater agreement between examiners. Mean accuracy for correctly predicting hemispheric location was 73% (range, 65% to 82%) with the most common error occurring in eyes with both superior and inferior 10-2 VF defects in which one hemisphere was correctly identified but the other missed.

CONCLUSIONS

In this study, the presence/absence of 10-2 glaucomatous VF loss was highly predictable using standard functional and structural clinical metrics. These findings suggest that 10-2 VF testing is not needed to reliably recognize and confirm central VF involvement in most eyes with glaucoma. Whether error related to identifying second hemisphere involvement in 10-2 VF loss is important requires further study.

Central Visual Field Defects in Patients with Distinct Glaucomatous Optic Disc Phenotypes

PURPOSE

To investigate central visual field (VF) defects among 4 phenotypes of glaucomatous optic discs.

DESIGN

Cross-sectional study.

METHODS

Optic disc phenotypes were determined in eyes with definite or suspected glaucoma that had a 24-2 VF with mean deviation (MD) better than -12 dB and a 10-2 VF. 10-2 VFs were classified as abnormal based on a cluster criterion. Additionally, the average of the total deviation values at each 10-2 test point was compared by optic disc phenotype.

RESULTS

The following 4 glaucomatous optic disc phenotypes were identified in 448 eyes of 309 patients: focal ischemic (FI) (n = 121); generalized cup enlargement (GE) (n = 109); myopic glaucoma (MY) (n = 66); and senile sclerotic (SS) (n = 152). Although 24-2 VF MD values were similar among optic disc phenotypes, GE eyes had higher 10-2 VF MD (P = .004), as well as lower 24-2 VF pattern standard deviations (PSD) (P < .001) and VF 10-2 PSD (P < .001) than the other phenotypes. The prevalence of an abnormal VF 10-2 was highest in FI eyes (78.5%) and lowest in GE eyes (50.5%) (P < .001). In glaucoma suspects, the prevalence of an abnormal 10-2 VF was highest in the MY eyes (31.2%) and FI eyes (23.5%) and lowest in GE eyes (8.6%). In mild glaucoma, the prevalence of abnormal 10-2 VF test results was highest in FI eyes (79.2%) and lowest in GE eyes (44.4%) (P = .013).

CONCLUSIONS

The severity and prevalence of central VF loss varied among different glaucomatous optic disc phenotypes. Glaucomatous eyes with FI and MY optic disc phenotypes are more likely to have 10-2 VF loss, particularly in early disease, and especially may benefit from testing with both 10-2 and 24-2 VF tests.

Disc Hemorrhages Are Associated With the Presence and Progression of Glaucomatous Central Visual Field Defects

PRECIS

In this prospective cohort study, disc hemorrhages were associated with more severe central damage on 24-2 and 10-2 visual fields (VFs), and faster progression globally on 24-2 VFs and centrally on 10-2 VFs.

PURPOSE

To study the relationship between disc hemorrhage (DH) and the presence and progression of glaucomatous central VF damage.

METHODS

Cross-sectional and longitudinal analyses were performed on data from the African Descent and Glaucoma Evaluation Study (ADAGES) cohort. Two masked investigators reviewed disc photographs for the presence and location of DH. 24-2 central VF damage was based on the number of test locations within the central 10 degrees of the 24-2 field pattern deviation and their mean total deviation (MTD). 10-2 central VF damage was based on pattern deviation and MTD. Main outcome measures were the association between DH and presence of central VF damage and between DH and worsening of VF.

RESULTS

DH was detected in 21 of 335 eyes (6.2%). In the cross-sectional analysis, DH was significantly associated with more severe central damage on 24-2 [incidence rate ratio=1.47; 95% confidence interval (CI)=1.02-2.12; P=0.035] and 10-2 VFs (incidence rate ratio=1.81; 95% CI=1.26-2.60; P=0.001). In the longitudinal analysis, DH eyes progressed faster than non-DH eyes based on 24-2 global MTD rates (difference in slopes, β=-0.06; 95% CI=-0.11 to -0.01; P=0.009) and 10-2 MTD rates (β=-0.10; 95% CI=-0.14 to -0.06; P< 0.001), but not 24-2 central MTD rates (β=-0.02; 95% CI=-0.078 to 0.026; P=0.338).

CONCLUSION

DH was associated with the presence and progression of central VF defects. DH identification should prompt intensive central VF monitoring and surveillance with 10-2 fields to detect progression.

Baseline Age and Mean Deviation Affect the Rate of Glaucomatous Vision Loss

PURPOSE

The purpose of this study was to assess the relationship between the rate of the glaucomatous visual field (VF) worsening and baseline age and baseline VF mean deviation (MD).

DESIGN

This study was a retrospective, multisite cohort.

PARTICIPANTS

A total of 84,711 reliable Swedish Interactive Thresholding Algorithm 24-2 VF tests from 8167 eyes from 5644 patients with ≥6 VF tests, ≥5 years of follow-up, baseline age 18 years or above and baseline MD ≥-10 dB, and at least 2 abnormal VF tests were included from the Glaucoma Research Network Database.

METHODS

The global mean deviation rates (MDRs) and pointwise total deviation rates (TDRs) of VF progression (dB/y) were calculated for each eye using linear regression. The relationships between MDR and baseline age and MD were determined using linear mixed-effects models and logistic regression, with rapid progression defined as an MDR≤-1.0 dB/y. The relationships between TDR and baseline age and baseline MD were determined using linear mixed-effects models.

MAIN OUTCOME MEASURES

Coefficients of the regression models.

RESULTS

In individual mixed-effects models both baseline age (β=-0.0079 dB/y; P<0.001) and baseline MD (β=0.012/y; P<0.001) were associated with faster progression. All parameters were statistically significant in the full model with both parameters and their interaction (β=0.00065; P=0.0017) as covariates. With logistic regression, each year increase in baseline age increased the odds of belonging to the rapid-progressing group by a factor of 1.033, and each unit increase in baseline MD (less severe visual loss) decreased the odds by a factor of 0.8821. The mean pointwise TDR ranged from -0.21 to -0.55 dB/y, with the most rapid pointwise progression observed in the nasal and paracentral regions of the field.

CONCLUSIONS

Older age and worse MD at baseline are associated with more rapid VF progression in this large dataset. The effect of age on MDR is influenced by baseline MD severity, supporting the importance of early detection and more aggressive therapy in older patients with worse VF damage. The pointwise rate of VF loss varies across the VF, providing a means for physicians to more effectively monitor progression.

Choroidal Microvasculature Dropout is Associated with Generalized Choroidal Vessel Loss within the β-Parapapillary Atrophy in Glaucoma

PURPOSE

To determine whether eyes with open-angle glaucoma (OAG) and a localized choroidal microvasculature dropout (MvD) are associated with a greater degree of generalized choroidal vascular insufficiency within the β-parapapillary atrophy (β-PPA) than OAG eyes without MvD.

DESIGN

Retrospective cross-sectional study.

METHODS

This study included 100 OAG eyes with visual field (VF) loss confined to a single hemifield (50 with and 50 without MvD, matched for age [≤10 years ols], axial length [≤1 mm], and VF severity [≤1 dB]), as well as 50 healthy eyes. Using optical coherence tomography angiography, parapapillary choroidal vessel density (pCVD) was measured on en-face images of choroidal maps within the entire β-PPA after excluding the MvD area and hemi-sectors of the β-PPA. pCVDs were compared among the 3 groups. The relationships between pCVD outcomes and various clinical variables were assessed. Logistical regression analyses were performed to determine the clinical factors associated with the presence of MvD in eyes with OAG.

RESULTS

pCVDs corresponding to the VF-intact hemi-sectors and the entire β-PPA, excluding the MvD area, were significantly lower in eyes with MvD than in matched sectors of eyes without MvD. Multivariate linear regression analysis showed that the presence of MvD and greater MvD angular extent were independently associated with lower global pCVD in OAG eyes (all P < .05). Logistic regression analyses showed that lower pCVD was the only factor significantly associated with the presence of MvD.

CONCLUSIONS

Localized MvD was a strong predictor of generalized pCVD loss within the β-PPA in OAG eyes.

Baseline Central Visual Field Defect as a Risk Factor For NTG Progression: A 5-Year Prospective Study

PRECIS

This 5-year follow-up study on normal-tension glaucoma (NTG) patients demonstrated that those with baseline central visual field (VF) defect progress at a more increased rate compared with those with peripheral field defect.

PURPOSE

The purpose of this study was to investigate the clinical characteristics, including 24-hour ocular perfusion pressure and risk of progression in patients with baseline central VF defect, as compared with those with peripheral VF defect in NTG.

DESIGN

This was a prospective, longitudinal study.

METHODS

A total of 65 NTG patients who completed 5 years of follow-up were included in this study. All the enrolled patients underwent baseline 24-hour intraocular pressure and blood pressure monitoring via 2-hourly measurements in their habitual position and had ≥5 reliable VF tests during the 5-year follow-up. Patients were assigned to two groups on the basis of VF defect locations at baseline, the central 10 degrees, and the peripheral 10- to 24-degree area. Modified Anderson criteria were used to assess global VF progression over 5 years. Kaplan-Meier analyses were used to compare the elapsed time of confirmed VF progression in the two groups. Hazard ratios for the association between clinical risk factors and VF progression were obtained by using Cox proportional hazards models.

RESULTS

There were no significant differences between the patients with baseline central and peripheral VF defects in terms of demography, clinical, ocular and systemic hemodynamic factors. Eyes with baseline defects involving the central fields progressed faster (difference: βcentral=-0.78 dB/y, 95% confidence interval=-0.22 to -1.33, P=0.007) and have 3.56 times higher hazard of progressing (95% confidence interval=1.17-10.82, P=0.025) than those with only peripheral defects.

CONCLUSION

NTG patients with baseline central VF involvement are at increased risk of progression compared with those with peripheral VF defect.

The Relationship Between Intraocular Pressure and Rates of Central Versus Peripheral Visual Field Progression

PRECIS

In this longitudinal prospective cohort study of open-angle glaucoma patients, intraocular pressure (IOP) parameters (mean, fluctuation, and maximum) had a similar effect on glaucomatous progression in the central and peripheral visual field (VF) regions.

PURPOSE

To study the effects of IOP on rates of glaucomatous central versus peripheral VF progression.

METHODS

The African Descent and Glaucoma Evaluation Study (ADAGES) is a longitudinal prospective cohort study that recruited patients from 3 centers. A sample of those with established glaucoma were included in this study. The mean peripheral sensitivity (MPS) and the mean central sensitivity (MCS) were defined based upon the average total deviation of the peripheral and central (10 degrees) points of the 24-2 VF, respectively. Progression was based upon central and peripheral change from linear mixed-effects models. The relationships between VF progression and IOP mean, maximum, and fluctuation as continuous variables were also investigated. Main outcome measures were MPS and MCS progression rates.

RESULTS

A total of 452 eyes of 344 patients were studied. The mean number of VFs (SD) for each eye was 13.3 (6.4) over 9.1 (3.7) years. The mean baseline MD was -5.1 (3.9) dB and the mean rate of MD change was -0.26 dB/y [95% confidence interval (CI): -0.33 to -0.20, P<0.001]. Mean rates of MPS (-0.27 dB/y, 95% CI: -0.33 to -0.22, P<0.001) and MCS change (-0.26 dB/y, 95% CI: -0.31 to -0.21, P<0.001) were similar (P=0.351). Mean, fluctuation, and maximum IOP were significantly associated with MPS and MCS (all P<0.025).

CONCLUSIONS

The effect of IOP parameters on VF progression was statistically similar between central and peripheral VF regions.

Rapid Central Visual Field Progression Rate in Eyes with Open-Angle Glaucoma and Choroidal Microvasculature Dropout

Central visual field (CVF) loss has been linked to poorer vision-related quality of life in eyes with open-angle glaucoma (OAG) and can occur even in early-stage OAG eyes. The present study investigated whether the detection of choroidal microvasculature dropout (CMvD) during follow-up, which may be a sign of perfusion deficiency in the optic nerve head, is associated with rapid rate of CVF loss in early-stage OAG eyes. This study included 44 Korean OAG eyes with CMvD, identified by optical coherence tomography angiography, and 44 Korean OAG eyes without CMvD matched for age and severity of visual field loss at initial presentation. The rates of mean threshold changes in global and CVF were compared in eyes with and without CMvD using a linear mixed model. Clinical variables associated with rapid rate of CVF progression were also identified using a linear mixed model. The CVF progression rate was significantly higher in eyes with CMvD than in those without CMvD (-0.584 dB/year vs. -0.190 dB/year; P < 0.001) and detection of CMvD during follow-up was an independent predictor of rapid CVF progression rate. The presence of CMvD may aid in identification of high-risk patients who may show faster CVF progression and require more aggressive treatment.