Patterns of glaucomatous visual field progression identified by three progression criteria

doi:10.1016/j.ajo.2004.07.003

American Journal of Ophthalmology

Volume 138, Issue 6, December 2004, Pages 1029-1036

https://doi.org/10.1016/j.ajo.2004.07.003 Get rights and content

Purpose

To determine typical patterns of repeatable glaucomatous visual field progression.

Design

Retrospective analysis of data obtained from two prospective studies.

Methods

Included were 72 eyes of 72 patients tested up to six times over 2 years, and 40 eyes of 40 patients followed annually for up to 12 years. Each patient had two abnormal baseline visual fields, abnormal optic nerves, and serial fields. Progression was identified using three methods: by glaucoma change probability using total deviation (GCP-TD) and pattern deviation (GCP-PD) plots and by a clinical criteria. Progression was categorized as deepening or expansion of an existing scotoma, or a new scotoma.

Results

The percentage of eyes repeatably progressed ranged from 17% to 27%. The most common pattern of progression was a deepening of an existing scotoma in the annual group, followed by expansion. With two follow-ups required, percentages for deepening only were 20% (clinical classifier). A combination of expansion and deepening was most common for the GCP criteria: 15% (GCP-TD classifier), and 10% (GCP-PD classifier) for the annual group. For the semiannual group, deepening was most common with the clinical criteria (11% of eyes), and deepening with expansion was most common by GCP criteria (14%, GCP-TD and GCP-PD). No eyes showed repeatable new scotomas.

Conclusions

Glaucomatous visual fields progress in the area of the visual field where baseline testing showed an existing scotoma. Follow-up testing might be improved by concentrating on already defective locations and using sparser test patterns or screening algorithms in normal areas of the visual field.

Section snippets

Subjects

Included in this analysis of serial visual fields were 112 eyes of 112 patients with glaucoma. The study eye was selected randomly. These patients came from two studies. The first was a prospective multicenter study in which 72 patients were followed at 3, 6, 12, 18, and 24 months. Hereafter, this group will be referred to as the “semiannual” group. Progression on visual fields was defined by the clinical criteria listed below. When progression was noted, a follow-up field was scheduled within

Results

Baseline mean deviations for abnormal and progressed visual field locations versus abnormal and nonprogressed locations were within 1.0 dB (−5.3 ± 5.6 and −4.4 ± 5.0, respectively). Eyes in the semiannual group had a minimum of four fields and a maximum of six fields. Eyes in the annual group had a minimum of four and a maximum of 17 follow-up fields.

Discussion

As has been shown in earlier studies, progression criteria comparable to those in our study do not always identify the same eyes as progressed or even the same number of progressed eyes.10, 11, 18, 24 For instance, clinical criteria for progression similar to those employed here tend to indicate more eyes as progressed than the GCP using total deviation. Additionally, the GCP using the total deviation plot tends to signal more eyes as progressed than does the GCP using pattern deviation. The

References (25)

F.S. Mikelberg et al.
The mode of progression of visual field defects in glaucoma
Am J Ophthalmol
(1984)
M.C. Leske et al.
Early Manifest Glaucoma Trialdesign and baseline data
Ophthalmology
(1999)
D.C. Musch et al.
The Collaborative Initial Glaucoma Treatment Studystudy design, methods, and baseline characteristics of enrolled patients
Ophthalmology
(1999)
F.S. Mikelberg et al.
The mode of progression of visual field defects in glaucoma
Am J Ophthalmol
(1984)
J. Katz et al.
Estimating progression of visual field loss in glaucoma
Ophthalmology
(1997)
E.Z. Blumenthal et al.
Evaluating several sources of variability for standard and SWAP visual fields in glaucoma patients, suspects, and normals
Ophthalmology
(2003)
A.C. Lee et al.
Infrequent confirmation of visual field progression
Ophthalmology
(2002)
J. Flammer et al.
Differential light threshold. Short- and long-term fluctuation in patients with glaucoma, normal controls, and patients with suspected glaucoma
Arch Ophthalmol
(1984)
J.M. Wild et al.
Long-term follow-up of baseline learning and fatigue effects in automated perimetry of glaucoma and ocular hypertensive patients
Acta Ophthalmol
(1991)
M.K. Birch et al.
Determining progressive visual field loss in serial Humphrey visual fields
Ophthalmology
(1995)

J.L. Keltner et al.

Confirmation of visual field abnormalities in the ocular hypertension treatment study

Arch Ophthalmol

(2000)

Advanced Glaucoma Intervention Study. 2. Visual field test scoring and reliability

Ophthalmology

(1994)

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Glaucomatous visual field progression has both personal and societal costs and therefore has a serious impact on quality of life. At the present time, intraocular pressure (IOP) is considered to be the most important modifiable risk factor for glaucoma onset and progression. Reduction of IOP has been repeatedly demonstrated to be an effective intervention across the spectrum of glaucoma, regardless of subtype or disease stage. In the setting of approval of IOP-lowering therapies, it is expected that effects on IOP will translate into benefits in long-term patient-reported outcomes. Nonetheless, the effect of these medications on IOP and their associated risks can be consistently and objectively measured. This helps to explain why regulatory approval of new therapies in glaucoma has historically used IOP as the outcome variable. Although all approved treatments for glaucoma involve IOP reduction, patients frequently continue to progress despite treatment. It would therefore be beneficial to develop treatments that preserve visual function through mechanisms other than lowering IOP. The United States Food and Drug Administration (FDA) has stated that they will accept a clinically meaningful definition of visual field progression using Glaucoma Change Probability criteria. Nonetheless, these criteria do not take into account the time (and hence, the speed) needed to reach significant change. In this paper we provide an analysis based on the existing literature to support the hypothesis that decreasing the rate of visual field progression by 30% in a trial lasting 12–18 months is clinically meaningful. We demonstrate that a 30% decrease in rate of visual field progression can be reliably projected to have a significant effect on health-related quality of life, as defined by validated instruments designed to measure that endpoint.
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This is again an expected result because the same amount of visual field loss over time is likely to have greater impact in the ability to perform daily activities for patients who start off with worse visual fields. Previous studies have shown that visual field defects in glaucoma tend to progress by deepening, expansion of an existing scotoma, or a combination of both.23,24 Therefore, patients with greater inferior or central visual field defects in both eyes at baseline are likely to need more close monitoring and to be candidates for more aggressive treatment.
To evaluate the association between rates of progressive loss in different regions of the visual field and longitudinal changes in quality of life (QoL).
Prospective, observational cohort study.
The study included 236 patients with glaucomatous visual field loss followed for an average of 4.3±1.5 years.
All subjects had the 25-item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) performed annually and standard automated perimetry (SAP) at 6-month intervals. Subjects were included if they had a minimum of 2 NEI VFQ-25 and 5 SAP tests during follow-up. Evaluation of rates of visual field change was performed using 4 different regions (central inferior, central superior, peripheral inferior, and peripheral superior) of the integrated binocular visual field. The association between change in NEI VFQ-25 Rasch-calibrated scores and change in different regions of the visual field was investigated with a joint multivariable longitudinal linear mixed model.
The relationship between change in QoL scores and change of mean sensitivity in different regions of the visual field.
There was a significant correlation between change in the NEI VFQ-25 Rasch scores during follow-up and change in different regions of the visual field. Each 1 decibel (dB)/year change in binocular mean sensitivity of the central inferior area was associated with a decline of 2.6 units/year in the NEI VFQ-25 scores (R² = 35%; P < 0.001). Corresponding associations with change in QoL scores for the peripheral inferior, central superior, and peripheral superior areas of the visual field had R² values of 30%, 24%, and 19%, respectively. The association for the central inferior visual field area was statistically significantly stronger than those of the central superior area (P = 0.011) and peripheral superior area (P = 0.001), but not the peripheral inferior area (P = 0.171). Greater declines in NEI VFQ-25 scores were also seen in patients who had worse visual field sensitivity at baseline.
Progressive decline in sensitivity in the central inferior area of the visual field had the strongest association with longitudinal decline in QoL of patients with glaucoma.
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2015, Glaucoma: Second Edition
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However, the number of significantly progressing VF test points was similar between the 2 groups. Considering that the most common pattern of glaucomatous VF progression is a deepening of an existing VF defect, followed by its expansion,34 our result suggests that the rate of VF defect deepening is faster in the eyes with focal LC defects than in the eyes without, but that the rate of VF defect expansion is similar between the 2 groups. Reasons for the increased risk and faster rate of VF progression in the eyes with focal LC defects compared with those in the eyes without are unclear.
To evaluate the association between focal, structural defects of the lamina cribrosa (LC) and glaucomatous visual field (VF) progression.
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A total of 169 patients with glaucoma (169 eyes) with a range of glaucomatous damage.
Serial horizontal and vertical enhanced-depth imaging optical coherence tomography (EDI OCT) B-scans of the optic nerve head were obtained from patients with glaucoma with 5 or more prior Humphrey 24-2 VFs (Carl Zeiss Meditec, Inc, Dublin, CA). The EDI OCT scans were reviewed for the presence of focal LC defects (laminar holes or disinsertions with a diameter >100 μm). The VF progression was defined as having ≥2 significantly progressing test points (with a slope calculated using pointwise linear regression [PLR], worse than −1.0 dB/year at P<0.01). Age, intraocular pressure (IOP), baseline VF mean deviation (MD), disc hemorrhage, and central corneal thickness (CCT) were recorded.
The relationship between focal LC defects and the rate and risk of VF progression.
Mean age and VF MD at the time of EDI OCT were 69±12 years and −11.49±6.87 dB, respectively. Sixty eyes (36%) progressed according to PLR criteria. Progression was more common in eyes with, rather than without, focal LC defects (38/81 eyes [47%] vs. 22/88 eyes [25%], P = 0.003). Among the evaluated parameters, the presence of focal LC defects, disc hemorrhage, higher mean follow-up IOP, greater number of VFs, and longer follow-up period were significantly associated with VF progression in the multivariable analyses (odds ratios, 2.90, 4.66, 1.22, 1.25, and 1.27, respectively; P = 0.010, P = 0.002, P = 0.002, P<0.001, and P<0.001, respectively). The mean global progression rate was significantly faster in the group with focal LC defect than in the group with no focal LC defect (−0.54±0.99 dB/year vs. −0.28±0.52 dB/year; P = 0.031). Among the 60 progressing eyes, despite no significant difference in the mean number of progressing VF points per eye (6.7±7.0 vs. 6.5±4.4; P = 0.899), the mean localized progression rate was significantly faster in the eyes with focal LC defects than in the eyes with no focal LC defects (−2.85±1.85 dB/year vs. −1.75±0.56 dB/year; P = 0.009).
Focal LC defects are strongly associated with glaucomatous VF progression, and eyes with focal LC defects tend to progress faster than those without.
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Linear regression can be applied to global indices, to clusters, or to individual points. Because progression may occur either through an expansion of an existing scotoma or through a general depression across the entire visual field, it is clinically relevant to assess change with global and local measurements.12,14,25 Linear regression applied to global indices and individual locations, and event-based analyses may each identify progression in different eyes.
Clinicians who manage glaucoma patients carefully monitor the visual field to determine if treatments are effective or interventions are needed. Visual field tests may reflect disease progression or variability among examinations. We describe the approaches and perimetric tests used to evaluate glaucomatous visual field progression and factors that are important for identifying progression. These include stimulus size, which area of the visual field to assess (central versus peripheral), and the testing frequency, evaluating which is important to detect change early while minimizing patient testing burden. We also review the different statistical methods developed to identify change. These include trend- and event-based analyses, parametric and nonparametric tests, population-based versus individualized approaches, as well as pointwise and global analyses. We hope this information will prove useful and important to enhance the management of glaucoma patients. Overall, analysis procedures based on series of at least 5 to 6 examinations that require confirmation and persistence of changes, that are guided by the pattern and shape of the glaucomatous visual field deficits, and that are consistent with structural defects provide the best clinical performance.
Detecting Glaucoma Progression Using Guided Progression Analysis with OCT and Visual Field Assessment in Eyes Classified by International Classification of Disease Severity Codes
2019, Ophthalmology Glaucoma
To compare the detection and rates of progressive retinal nerve fiber layer (RNFL) and ganglion cell–inner plexiform layer (GCIPL) loss with spectral-domain (SD) OCT and visual field (VF) loss using Guided Progression Analysis (GPA; Carl Zeiss Meditec, Dublin, CA) in glaucomatous eyes classified using International Classification of Diseases (ICD) diagnosis codes.
Retrospective cohort study.
Glaucoma patients with at least 3 years of follow-up and a minimum of 4 SD OCT and 5 reliable VF examinations.
Glaucoma severity was classified using ICD, 10th Edition, Clinical Modification, diagnosis codes. Rates of RNFL, macular GCIPL, and VF loss were calculated, and progression estimates were compared using generalized estimating equations and McNemar’s tests.
Progressive RNFL, GCIPL, and VF loss assessed by GPA criteria.
A total of 147 eyes of 116 patients (mean age, 69.9±8.5 years) were included with mean follow-up of 69.67±18.64 months. Overall, 38 of 147 eyes (25.9%) showed RNFL progression, 35 eyes (23.8%) showed GCIPL progression, and 20 eyes (13.6%) showed VF progression. Progression by all 3 methods was noted in 10 eyes (7.0%). Eyes with mild (n = 62) and severe (n = 46) glaucoma showed significantly more progression on SD OCT compared with VF (P < 0.001 and P = 0.004). Retinal nerve fiber layer, GCIPL, and VF progressors showed faster rates of loss in average RNFL, GCIPL, and VF mean deviation compared with nonprogressors (mean ± standard error: –1.47±0.30 μm/year vs. –0.03±0.12 μm/year [P = 0.0001], –1.68±0.34 μm/year vs. –0.29±0.07 μm/year [P = 0.0001], and –1.07±0.20 dB/year vs. –0.19±0.04 dB/year [P = 0.0001], respectively).
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: This research was supported by a grant from the National Eye Institute, NEI EY 08208 (P.A.S.), Glaucoma Research Foundation (P.A.S.), Research to Prevent Blindness and Alcon (P.A.S.), Foundation for Eye Research (E.Z.B., F.M.). Research support from Carl-Zeiss Meditec, Inc. (P.A.S., R.N.W.).

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Patterns of glaucomatous visual field progression identified by three progression criteria

Purpose

Design

Methods

Results

Conclusions

Section snippets

Subjects

Results

Discussion

Am J Ophthalmol

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Differential light threshold. Short- and long-term fluctuation in patients with glaucoma, normal controls, and patients with suspected glaucoma

Arch Ophthalmol

Long-term follow-up of baseline learning and fatigue effects in automated perimetry of glaucoma and ocular hypertensive patients

Acta Ophthalmol

Determining progressive visual field loss in serial Humphrey visual fields

Ophthalmology

Confirmation of visual field abnormalities in the ocular hypertension treatment study

Arch Ophthalmol

Advanced Glaucoma Intervention Study. 2. Visual field test scoring and reliability

Ophthalmology