A qualitative investigation into patients' views on visual field testing for glaucoma monitoring

OBJECTIVES

To investigate the views and experiences of patients regarding their glaucoma follow-up, particularly towards the type and frequency of visual field (VF) testing.

DESIGN

A qualitative investigation using focus groups. The group discussion used broad open questions around the topics in a prompt guide relating to experiences of glaucoma follow-up, and in particular, VF monitoring. All the groups were taped, transcribed and coded using manual and computer-aided methods.

SETTING

Three National Health Service (NHS) hospitals in England; two focus groups took place at each hospital.

PARTICIPANTS

28 patients (mean (SD) age: 74 (9) years; 54% women) diagnosed with glaucoma for at least 2 years. Each focus group consisted of 3-6 patients.

PRIMARY AND SECONDARY OUTCOMES

(1) Attitudes and experiences of patients with glaucoma regarding VF testing. (2) Patients' opinions about successful follow-up in glaucoma.

RESULTS

These patients did not enjoy the VF test but they recognised the importance of regular monitoring for preserving their vision. These patients would agree to more frequent VF testing on their clinician's recommendation. A number of themes recurred throughout the focus groups representing perceived barriers to follow-up care. The testing environment, waiting times, efficiency of appointment booking and travel to the clinic were all perceived to influence the general clinical experience and the quality of assessment data. Patients were also concerned about aspects of patient-doctor communication, and often received little to no feedback about their results.

CONCLUSIONS

Patients trust the clinician to make the best decisions for their glaucoma follow-up. However, patients highlighted a number of issues that could compromise the effectiveness of VF testing. Addressing patient-perceived barriers could be an important step for devising optimal strategies for follow-up care.

Learning effect of Humphrey Matrix perimetry

BACKGROUND

Humphrey Matrix perimetry is a recent development in automated perimetry that uses frequency-doubling technology (FDT). We evaluated the learning effect of Humphrey Matrix perimetry with a full-threshold 30-2 strategy.

METHODS

Twenty-four patients with primary open-angle glaucoma and early visual field defects as assessed by standard automated perimetry and 24 healthy control subjects participated. All subjects had no prior experience with FDT visual field tests. Humphrey Matrix perimetry using a full-threshold 30-2 strategy was performed 3 times within 1 month. Various visual field indices were compared across multiple tests.

RESULTS

Mean deviation (MD) showed a larger defect at the first test than at the second and third tests (p < 0.001), and the mean total improvement of the MD was 2.80 decibels (dB) in the glaucoma group and 1.71 dB in the control group. Pattern standard deviations (PSDs) were decreased as the tests were repeated, but test duration, fixation losses, and false-positive or false-negative rate were not changed significantly. Additionally, the Glaucoma Hemifield Test (GHT) showed unstable results.

INTERPRETATION

In patients naive to the FDT test, Humphrey Matrix perimetry showed a large learning effect on MD and PSD among the various visual field indices. The GHT results of Humphrey Matrix perimetry showed a large instability.

Learning effect, normal range, and test-retest variability of Frequency Doubling Perimetry as a function of age, perimetric experience, and the presence or absence of glaucoma

The learning effect for several different Frequency Doubling Perimetry parameters was studied in full threshold mode in a large group of patients (n = 342) of various ages, with and without perimetric experience, and with and without glaucoma. A significant learning effect was only found for the mean deviation (MD) in aged normals without perimetric experience. The median of MD increased for both OD (from +0.2 to +1.0 dB) and for OS (from +0.5 to +1.3 dB). The effect disappeared largely during a third visit (median OD +1.2 dB, OS +1.3 dB). The normal range and the test-retest variability were measured in the same dataset. The learning effect for MD (1 dB or less) appeared to be small as compared with both the normal range (about 12 dB) and the test-retest variability (about 3 dB).

[Visual field examination in limited patient cooperation]

Objective methods to estimate the visual field are necessary, if a conventional subjective perimetry is impossible due to limited cooperation. Objective methods are indicated in infants, handicapped patients, patients with psychogenic visual field loss, and malingerers. An objective estimation of the visual field can be performed by means of pupillary light reflexes, voluntary and involuntary eye movements, and visual evoked potentials. Systematically false responses contain useful information regarding the proof of misrepresentations. The reproducibility of visual field defects can be checked by testing at different distances from the screen. This article reports on handy methods requiring no large-scale equipment.

Changes of glaucomatous field defects. Degree of accuracy of measurements with the automatic perimeter Octopus

The analytical programme Delta was used to determine longterm fluctuation and accuracy of measurement of the programme 31 of Octopus when used on glaucoma patients. Programme 31 examines the 30 degrees field. The test locations are arranged in a square grid with 6 degrees resolution. The programme Delta determines and compares 1) the disturbed area in %; 2) the total loss, the total sensitivity being around 2000 dB; 3) the loss in dB per mean number of disturbed points. Thirty-two eyes of 22 patients with established glaucomatous field defects were examined twice within two to six days and two months later again twice. The size of the disturbed area served for classification of our sample into three groups: 1st group: disturbed area 1-33%; 2nd group: disturbed area 34-66%; 3rd group: disturbed area 67-100%. Long-term fluctuations and accuracy of measurement could be determined as respectively follows: 1) Disturbed area between 0.7 +/- 8% in group 3 and 1.7 +/- 13% in group 2. 2) The total loss increases proportionately to the disturbed area and was 4.9 +/- 29.2 dB in group 1 and 31.8 +/- 82.4 dB in group 3. 3) The total loss per mean number of disturbed points was 0.5 +/- 2 dB in group 1 and 0.3 +/- 1.2 dB in group 2. This signifies that if the learning effect is over, changes of more than 2 dB, especially if several adjacent points are affected, are a significant loss. The learning effect, as determined in an earlier study, may go up as high as 2 dB per point.