Relationship between Intraocular Pressure Fluctuation and Visual Field Progression Rates in the United Kingdom Glaucoma Treatment Study.

PURPOSE: To investigate whether intraocular pressure (IOP) fluctuation is associated independently with the rate of visual field (VF) progression in the United Kingdom Glaucoma Treatment Study. DESIGN: Randomized, double-masked, placebo-controlled multicenter trial. PARTICIPANTS: Participants with ≥5 VFs (213 placebo, 217 treatment). METHODS: Associations between IOP metrics and VF progression rates (mean deviation [MD] and five fastest locations) were assessed with linear mixed models. Fluctuation variables were mean Pascal ocular pulse amplitude (OPA), standard deviation (SD) of diurnal Goldmann IOP (diurnal fluctuation), and SD of Goldmann IOP at all visits (long-term fluctuation). Fluctuation values were normalized for mean IOP to make them independent from the mean IOP. Correlated nonfluctuation IOP metrics (baseline, peak, mean, supine, and peak phasing IOP) were combined with principal component analysis, and principal component 1 (PC1) was included as a covariate. Interactions between covariates and time from baseline modeled the effect of the variables on VF rates. Analyses were conducted separately in the two treatment arms. MAIN OUTCOME MEASURES: Associations between IOP fluctuation metrics and rates of MD and the five fastest test locations. RESULTS: In the placebo arm, only PC1 was associated significantly with the MD rate (estimate, -0.19 dB/year [standard error (SE), 0.04 dB/year]; P < 0.001), whereas normalized IOP fluctuation metrics were not. No variable was associated significantly with MD rates in the treatment arm. For the fastest five locations in the placebo group, PC1 (estimate, -0.58 dB/year [SE, 0.16 dB/year]; P < 0.001), central corneal thickness (estimate, 0.26 dB/year [SE, 0.10 dB/year] for 10 µm thicker; P = 0.01) and normalized OPA (estimate, -3.50 dB/year [SE, 1.04 dB/year]; P = 0.001) were associated with rates of progression; normalized diurnal and long-term IOP fluctuations were not. In the treatment group, only PC1 (estimate, -0.27 dB/year [SE, 0.12 dB/year]; P = 0.028) was associated with the rates of progression. CONCLUSIONS: No evidence supports that either diurnal or long-term IOP fluctuation, as measured in clinical practice, are independent factors for glaucoma progression; other aspects of IOP, including mean IOP and peak IOP, may be more informative. Ocular pulse amplitude may be an independent factor for faster glaucoma progression. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Visual field progression in open-angle glaucoma after refractive corneal ablation surgery.

This study aimed to investigate visual field (VF) progression in open-angle glaucoma (OAG) subjects who had a history of refractive corneal ablation surgery (RCAS). Retrospective study. The medical records of 21 subjects who had a history of refractive corneal ablation surgery (RCAS group) and 36 patients who had myopia without a history of RCAS (non-RCAS group) were reviewed. VF progression was determined by the non-parametric progression analysis (NPA) method. VF progression and clinical characteristics were compared between the two groups. For the RCAS group, refractive regressions were analysed. The mean follow-up periods were 4.5 years and 5.5 years for the RCAS and non-RCAS groups, respectively. More glaucoma subjects in the RCAS group (57.1%) had likely VF progression than in the non-RCAS group (25.0%) (p = 0.01). The RCAS group had a significantly lower percentage of IOP reduction with anti-glaucoma medication than the non-RCAS group (p = 0.037). Eyes with likely VF progression had a higher incidence of refractive regression (91.7%, 11/12) than eyes without it (33.3%, 3/9). Among subjects whose eyes had refractive regression, 78.6% (11/14) had likely VF progression, and 21.4% (3/14) did not (p = 0.016). The VF progression in OAG after RCAS was faster than that of myopic OAG without RCAS. Anti-glaucoma treatment should be actively enhanced in clinical practice.

Visual field progression in Malay patients with primary glaucoma: survival analysis and prognostic factors.

PURPOSE: This study aims to determine the 5-year visual field progression and identify the prognostic factors for progression in Malay patients with primary glaucoma. METHODS: A retrospective cohort record review study was conducted among 222 patients (222 eyes) with primary glaucoma who were selected from a glaucoma research database of a tertiary center in Malaysia. The patients were Malays and diagnosed with primary open-angle glaucoma (POAG) or primary angle-closure glaucoma (PACG). Patients who were followed up regularly for at least 6 months between 1 January 2009 and 31 December 2014 and completed another 1-year follow-up after recruitment (between 1 January 2015 and 31 December 2015) were selected. Multiple prognostic factors that influence visual field progression were identified. Progression of visual field loss was based on the Advanced Glaucoma Intervention Study and Hodapp-Parrish-Anderson scores. Kaplan-Meier survival and Cox proportional hazard regression analyses were performed. RESULTS: Sixty-three patients (28.4%) developed visual field progression after a mean (SD) follow-up of 6.9 (3.3) years. Those with POAG progressed faster (mean time, 10.6 years; 95% confidence interval [CI], 9.3, 11.9) than those with PACG (17.3 years; 95% CI, 14.8, 19.9) but not statistically significant. Disc hemorrhage and history of eye pain increased the risk of progression by 2.8-folds (95% CI, 1.6, 4.8) and 2.5-folds (1.4, 4.4), respectively. CONCLUSION: The 5-year survival of the Malay primary glaucoma patients with visual field progression was similar with that of other Asian populations. However, aggressive management is required for those with disc hemorrhages and eye pain related to increased intraocular pressure.

Comparison of visual field progression in new-diagnosed primary open-angle and exfoliation glaucoma patients in Sweden.

BACKGROUND: The present study aimed to compare visual field progression in new-diagnosed exfoliation versus open-angle glaucoma patients. METHODS: Retrospective study. The study included patients with new-diagnosed primary open-angle and exfoliation glaucoma. All patients were followed for 3 years with reliable visual fields. At least five reliable fields were needed for inclusion. Exfoliation and open-angle glaucoma were defined based on the European Glaucoma Society guidelines. Visual field evaluation was performed using the software threshold 24-2 of the Humphrey Field Analysis. OUTCOMES: Visual field progression. For visual field progression, three different strategies were used: mean deviation (MD), visual field index (VFI), and the guided progression analysis (GPA). RESULTS: The study included 128 subjects, of the 54 in the open-angle and 74 in the exfoliation glaucoma group. The MD difference values were higher in the exfoliation (- 3.17 dB) than in the primary open-angle (- 1.25 dB) glaucoma group in the three-year follow-up period. The difference between groups was significant (t-test, p = < 0.001). The difference in VFI was calculated for the 3 years follow-up period. The difference was higher in the exfoliation (- 7.65%) than in the primary open (- 1.90%) glaucoma group (t-test, p = < 0.001). The GPA showed progression in 58% of cases in exfoliation, and 13% in primary open glaucoma group (Chi-square, p = < 0.001). CONCLUSION: The present study found a more frequent and faster visual field progression in exfoliation than in primary open-angle glaucoma patients. New-diagnosed exfoliation glaucoma patients must be controlled and treated more strictly than primary open-angle glaucoma patients to avoid visual field deterioration.

Association between the Frequency of Optic Disk Hemorrhage and Progression of NTG Related with the Initial Location of RNFL Defect.

PURPOSE: This study aimed to investigate the association of the frequency of optic disk hemorrhage (DH) and progression of normal tension glaucoma (NTG) between each group based on the location of the initial retinal nerve fiber layer (RNFL) defect. METHODS: In this retrospective, observational cohort study, 142 NTG patients who underwent more than 5 reliable visual field tests with initial superior hemifield (group 2, n = 51), inferior hemifield (group 1, n = 44), or both hemifield (group 3, n = 47) defects were included. The number of DHs was inspected in serial optic disk photographs by 2 different ophthalmologists. Progression rates, which are the slope of mean thresholds from the 52 points, were calculated using a linear mixed effect model. RESULTS: The mean follow-up period was 8.19 ± 3.30 years. DHs related with the initial RNFL defect occurred significantly more frequently in group 2 (35 in inferior hemifield) than in group 1 (6 in superior hemifield) (p = 0.009) or group 3 (6 in inferior hemifield) (p = 0.006). The progression rate in group 2 was significantly faster than in group 1 (p = 0.019) or the superior hemifield of group 3 (p = 0.001). The progression rate of subjects showing recurrent DH was significantly faster than those showing single DH from all groups (-0.5460 vs. -0.2867 dB/year, p = 0.0053). CONCLUSIONS: More careful examination and caution are required when NTG patients show recurrent DH in the inferior hemifield related to the initial RNFL defect.

Clinical outcomes after Ex-PRESS glaucoma shunt versus non-penetrating deep sclerectomy: two-year follow-up.

PURPOSE: To compare the two-year outcomes of non-penetrating deep sclerectomy (NPDS) and Ex-PRESS glaucoma shunt. METHODS: A retrospective chart review of patients who had undergone NPDS or Ex-PRESS since 2012 was conducted. Patients were excluded if they had undergone eye surgery other than cataract extraction, were diagnosed with ocular pathology other than glaucoma or had less than two-year follow-up. Pre- and postoperative visual acuity, intraocular pressure (IOP), number of hypotensive drugs and visual fields were recorded, as well as intra- and postoperative complications. RESULTS: Thirty-nine eyes were included in the NPDS and twenty-three eyes in the Ex-PRESS group. There were no differences in baseline IOP and hypotensive drugs, IOP reduction or postoperative IOP-lowering medications between groups. Two years after surgery, IOP decrease compared to baseline was 23.5% with NPDS and 24.8% with Ex-PRESS. Qualified success (a 20% IOP reduction, with IOP ≤ 18 mmHg with or without medication) rates were similar: 53.8 and 69.6% for NPDS and Ex-PRESS. Visual fields progressed in four eyes of the NPDS (10.2%) and in three eyes (8.7%) of the Ex-PRESS group. As regards complications, early hypotony was more frequent after NPDS (9 eyes, 23.1%) than Ex-PRESS (2 eyes, 8.7%), although the difference was not statistically significant. CONCLUSIONS: Both NPDS and Ex-PRESS produce an IOP-lowering effect of approximately 25%. Success rates are similar after both procedures, and both seem to lead to a stabilization of visual loss.

Optic disc tilt direction affects regional visual field progression rates in myopic eyes with open-angle glaucoma.

PURPOSE: To compare global and regional visual field (VF) progression rates and determine clinical factors associated with rapid VF progression in myopic patients with open-angle glaucoma (OAG) with different disc tilt directions. METHODS: The medical records of 182 eyes from 182 myopic OAG patients with progressive VF deterioration during follow-up were analyzed. The rates of change in the mean thresholds of the global and regional VF areas of the horizontal and vertical disc tilt (HDT and VDT) groups were compared using a linear mixed model after controlling for confounding covariates. Clinical factors associated with rapid VF progression in global and regional VF areas were investigated. RESULTS: The VDT group showed significantly faster VF progression at inferior regional zones than the HDT group (P < 0.05). Based on a multivariate linear mixed model, VDT was associated with faster bi-hemifield VF progression in the GHT map, whereas HDT was associated with faster single-hemifield VF progression. CONCLUSIONS: Myopic OAG eyes show significantly different regional VF progression rates according to disc tilt direction. VDT is an independent predictor of a rapid rate of regional VF progression in both hemifields, whereas HDT predicts rapid regional VF progression in a single hemifield.

Understanding and identifying visual field progression.

Detecting deterioration of visual field sensitivity measurements is important for the diagnosis and management of glaucoma. This review surveys the current methods for assessing progression that are implemented in clinical devices, which have been used in clinical trials, alongside more recent advances proposed in the literature. Advice is also offered to clinicians on what they can do to improve the collection of perimetric data to help analytical progression methods more accurately predict change. This advice includes a discussion of how frequently visual field testing should be undertaken, with a view towards future developments, such as digital healthcare outside the standard clinical setting and more personalised approaches to perimetry.

Former smoking as a risk factor for visual field progression in exfoliation glaucoma patients in Sweden.

PURPOSE: The present study aimed to identify whether former smoking was a risk factor for visual field progression in exfoliation glaucoma patients. METHODS: Prospective nonrandomised cohort study. The study included patients diagnosed with exfoliation glaucoma. All included patients were followed for three years (± three months) with reliable visual fields. At least five reliable visual fields needed to be included in the study. Exfoliation glaucoma was defined using the European Glaucoma Society Guidelines. The visual fields were tested using the 24-2 test strategy of the Humphrey Field Analyzer. Smoking was assessed through questionnaires. Outcomes: Visual field progression. Three different approaches were used: difference in mean deviation (MD), rate of progression (ROP), and guided progression analysis (GPA). RESULTS: In total, n = 113 patients were included; among them, n = 57 were smokers. Smoking was a significant predictor for visual field progression in the three models (MD/ROP/GPA) studied (p = 0.01/p = 0.001/p ≤ 0.001), even adjusting for intraocular pressure (IOP). Other predictors were included in the MD model: IOP at diagnosis (p = 0.04) and selective laser trabeculoplasty (SLT) treatment (p = 0.01). Other predictors were in the ROP model: Visual field index (p = 0.005), number of medications (p = 0.001) and SLT treatment (p = 0.001). The number of medications was another predictor in the GPA model (p = 0.002). CONCLUSIONS: Former smoking induced visual field deterioration in all models studied. Smoking status should be considered when establishing the glaucoma diagnosis. Increased glaucoma care should be provided to former smokers to slow the progression of the disease.

Sector-specific Association of Intraocular Pressure Dynamics in Dark-room Prone Testing and Visual Field Defect Progression in Glaucoma.

PURPOSE: To investigate sectoral differences in the relationship between intraocular pressure (IOP) dynamics during dark-room prone testing (DRPT) and visual field (VF) defect progression in primary open-angle glaucoma (POAG) patients. DESIGN: Retrospective, longitudinal study. PARTICIPANTS: This retrospective study included 116 eyes of 84 POAG patients who underwent DRPT and had at least 5 reliable VF tests conducted over a more than 2-year follow-up period. We excluded eyes with mean deviation worse than -20 dB or a history of intraocular surgery or laser treatment. METHODS: Average total deviation (TD) was calculated in the superior, central, and inferior sectors of the Humphrey 24-2 or 30-2 program. During DRPT, IOP was measured in the sitting position, and after 60 minutes in the prone position in a dark room, IOP was measured again. The relationship between IOP change during DRPT, IOP after DRPT, and TD slope in each quadrant was analyzed with a linear mixed-effects model, adjusting for other potential confounding factors. MAIN OUTCOME MEASURES: Total deviation slope in each quadrant, IOP change during DRPT, and IOP after DRPT. RESULTS: Intraocular pressure after DRPT and IOP change during DRPT were 18.16 ± 3.42 mmHg and 4.92 ± 3.12 mmHg, respectively. Superior TD slope was significantly associated with both IOP after DRPT (ß = -0.28, P = 0.003) and IOP change during DRPT (ß = -0.21, P = 0.029), while central (ß = -0.05, P = 0.595; ß = -0.05; P = 0.622) and inferior (ß = 0.05, P = 0.611; ß = 0.01, P = 0.938) TD slopes were not. CONCLUSION: Dark-room prone testing might be a useful test to predict the risk of superior VF defect progression in eyes with POAG. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Metabolomics identifies and validates serum androstenedione as novel biomarker for diagnosing primary angle closure glaucoma and predicting the visual field progression.

Background: Primary angle closure glaucoma (PACG) is the leading cause of irreversible blindness in Asia, and no reliable, effective diagnostic, and predictive biomarkers are used in clinical routines. A growing body of evidence shows metabolic alterations in patients with glaucoma. We aimed to develop and validate potential metabolite biomarkers to diagnose and predict the visual field progression of PACG. Methods: Here, we used a five-phase (discovery phase, validation phase 1, validation phase 2, supplementary phase, and cohort phase) multicenter (EENT hospital, Shanghai Xuhui Central Hospital), cross-sectional, prospective cohort study designed to perform widely targeted metabolomics and chemiluminescence immunoassay to determine candidate biomarkers. Five machine learning (random forest, support vector machine, lasso, K-nearest neighbor, and GaussianNaive Bayes [NB]) approaches were used to identify an optimal algorithm. The discrimination ability was evaluated using the area under the receiver operating characteristic curve (AUC). Calibration was assessed by Hosmer-Lemeshow tests and calibration plots. Results: Studied serum samples were collected from 616 participants, and 1464 metabolites were identified. Machine learning algorithm determines that androstenedione exhibited excellent discrimination and acceptable calibration in discriminating PACG across the discovery phase (discovery set 1, AUCs=1.0 [95% CI, 1.00-1.00]; discovery set 2, AUCs = 0.85 [95% CI, 0.80-0.90]) and validation phases (internal validation, AUCs = 0.86 [95% CI, 0.81-0.91]; external validation, AUCs = 0.87 [95% CI, 0.80-0.95]). Androstenedione also exhibited a higher AUC (0.92-0.98) to discriminate the severity of PACG. In the supplemental phase, serum androstenedione levels were consistent with those in aqueous humor (r=0.82, p=0.038) and significantly (p=0.021) decreased after treatment. Further, cohort phase demonstrates that higher baseline androstenedione levels (hazard ratio = 2.71 [95% CI: 1.199-6.104], p=0.017) were associated with faster visual field progression. Conclusions: Our study identifies serum androstenedione as a potential biomarker for diagnosing PACG and indicating visual field progression. Funding: This work was supported by Youth Medical Talents - Clinical Laboratory Practitioner Program (2022-65), the National Natural Science Foundation of China (82302582), Shanghai Municipal Health Commission Project (20224Y0317), and Higher Education Industry-Academic-Research Innovation Fund of China (2023JQ006).

To compare central visual field progression using mean deviation and pointwise linear regression analysis.

Purpose: To compare central visual field progression using mean deviation and pointwise linear regression (PLR) analysis. Methods: We analyzed the 10-2 Humphrey visual field (HVF) tests for moderate and advanced primary glaucoma who had undergone at least five reliable 10-2 visual field tests with a minimum follow-up of at least two years and best-corrected visual acuity better than 6/12. Regression slope less than -1 dB/year at P < 0.01 at a point was defined as an individual threshold point progression. Results: Ninety-six eyes of 74 patients were included. The median follow-up duration was of 4 years (±1.97). Median 10-2 mean deviation (MD) at inclusion was -19.01 dB (interquartile range [IQR] -13.2, -24.14) and -21.90 (IQR - 13.4, -27.8) on 24-2 HVF. The median rate of MD change was -0.13 dB/year (IQR - 0.46, 0.08) for 10-2. The median rate for visual field index (VFI) change was 0.9% per year (IQR - 1.5, 0.4). Twenty-eight percent of eyes (27 eyes) showed progression. Twelve percent (12 eyes) showed progression of two or more points in the same hemifield on pointwise linear regression (PLR) analysis, and 16% of eyes (15 eyes) showed progression of one point. The median rate of MD change was significantly more in progressing eyes based on PLR analysis than eyes with no progression (-0.5 vs. -0.06 dB/year P < 0.001). One patient had likely and the second had possible progression on 24-2. In 24 eyes, event analysis did not show any change; the rest mean deviation was out of range. Conclusion: Central visual field PLR analysis is useful in detecting progression in advanced glaucomatous damage.

The role of corneal biomechanics in visual field progression of primary open-angle glaucoma with ocular normotension or hypertension: a prospective longitude study.

Introduction: To analyze effects of dynamic corneal response parameters (DCRs) on visual field (VF) progression in normal-tension glaucoma (NTG) and hypertension glaucoma (HTG). Methods: This was a prospective cohort study. This study included 57 subjects with NTG and 54 with HTG, followed up for 4 years. The subjects were divided into progressive and nonprogressive groups according to VF progression. DCRs were evaluated by corneal visualization Scheimpflug technology. General linear models (GLMs) were used to compare DCRs between two groups, adjusting for age, axial length (AL), mean deviation (MD), etc. VF progression risk factors were evaluated by logistic regression and receiver operating characteristic (ROC) curves. Results: For NTG, first applanation deflection area (A1Area) was increased in progressive group and constituted an independent risk factor for VF progression. ROC curve of A1Area combined with other relevant factors (age, AL, MD, etc.) for NTG progression had an area under curve (AUC) of 0.813, similar to the ROC curve with A1area alone (AUC = 0.751, p = 0.232). ROC curve with MD had an AUC of 0.638, lower than A1Area-combined ROC curve (p = 0.036). There was no significant difference in DCRs between the two groups in HTG. Conclusion: Corneas in progressive NTG group were more deformable than nonprogressive group. A1Area may be an independent risk factor for NTG progression. It suggested that the eyes with more deformable corneas may also be less tolerant to pressure and accelerate VF progression. VF progression in HTG group was not related to DCRs. Its specific mechanism needs further studies.

The Impact of Superficial Vessel Density on Glaucoma Progression according to the Stage of Glaucoma.

PURPOSE: To investigate the clinical significance of vessel density (VD) on visual field (VF) progression regarding the severity of glaucoma. METHODS: A total of 130 eyes were recruited in this retrospective and longitudinal study. Superficial and deep VDs in circumpapillary and macular regions were measured via ImageJ. The rate of VF progression was defined as the mean deviation (MD) slope (dB/year). Linear regression was used to verify factors affecting deterioration of VF. The eyes with lower superficial VD were further analyzed. RESULTS: Fifty patients with early glaucoma (EG) (MD > -6 dB) and 52 patients with moderate-to-advanced glaucoma (MAG) (MD ≤ -6 dB) were included. A faster progression rate was found in MAG (p = 0.049). Superficial VD was noticeably related to the VF progression rate in total eyes and in MAG (Both Ps ≤ 0.007, respectively). With patients in the lower half of the superficial VD, the VD was significantly associated with the rate of progression (B, 0.049, p = 0.021). This association was independent of the baseline MD and OCT parameters. CONCLUSION: Decreased superficial VD might conversely affect the progression of glaucoma even in MAG, which suggests superficial VD could be used as a potential marker to foresee the disease progression even in progressed eyes.

Evening exercise is associated with lower odds of visual field progression in Chinese patients with primary open angle glaucoma.

BACKGROUND: Exercise is widely known to lower intraocular pressure and increase ocular blood flow, which may be beneficial for glaucoma management. However, there are few studies that have reported on the relationship between exercise and glaucoma progression. The aim of our study was to investigate the exercise habits of those with primary open angle glaucoma (POAG) and its association with the progression of visual field (VF) loss. METHODS: Daily physical activity (PA) was monitored by an accelerometer (ActiGraph wGT3x-BT) which patients wore for more than 10 h of being awake on their right wrists for 1 week. RESULTS: Seventy-one non-progressive and 27 progressive patients were enrolled in the study. 24-h moderate to vigorous physical activity (MVPA) exercise showed that POAG patients had similar variation trends consisting of 3 wave peaks and 2 wave hollows. Minutes spent in MVPA was 19.89 ± 15.81 and 21.62 ± 15.10 during 07:00-09:00 h (p = 0.204), 15.40 ± 14.49 and 15.67 ± 12.43 during 15:00-17:00 h (p = 0.822) and 17.26 ± 21.11 and 11.42 ± 11.58 during 18:00-20:00 h (p = 0.001) in the non-progressive and progressive group, respectively. Univariate analysis indicated that 10 min of MVPA (18:00-20:00 h) [odds ratio, OR (95% CI) = 0.82 (0.73, 0.92)], average mean arterial pressure [OR (95% CI) = 0.96 (0.94, 0.98)], age [OR (95% CI) = 1.06 (1.03, 1.08)], male [OR (95% CI) = 0.67 (0.48, 0.96)], spherical equivalent [OR (95% CI) = 1.14 (1.07, 1.22)] and IOP-lowering medications [OR (95% CI) = 1.54 (1.16, 2.05)] were significantly correlated with having progressive VF damage. Multivariable analysis showed that 10 min of MVPA (18:00-20:00 h) [OR (95% CI) = 0.85 (0.75, 0.97)] was associated with progressive VF loss even after adjusting for other risk factors. CONCLUSIONS: Evening exercise may lower the odds of VF progression, suggesting that exercise habits possibly play an important role in glaucoma progression.

Functional assessment of glaucoma: Uncovering progression.

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.

Evaluation of Routine Health Examination for Screening Primary Open Angle Glaucoma in Eastern China: A Hospital-Based Cross-Sectional Study.

PURPOSE: To evaluate the effect of routine health examination (RHE) for screening primary open angle glaucoma (POAG) in Eastern China. MATERIALS AND METHODS: We enrolled patients with newly diagnosed and untreated POAG admitted to the Eye, Ear, Nose and Throat Hospital of Fudan University, Shanghai, China. Patients who were screened on RHE and then diagnosed with POAG were classified into the RHE group. The rest were classified as the non-RHE group. Demographic and ocular characteristics, 24-hour intraocular pressure (IOP), and glaucoma grade classified as the mild, moderate and severe groups according to glaucomatous optic neuropathy evaluated based on the enhanced Glaucoma Staging System were compared between the two groups. RESULTS: In total, 172 patients with POAG (74 cases in the RHE group and 98 cases in the non-RHE group) were enrolled. The average age of patients in the RHE and non-RHE groups was 47.53 ± 1.48 years and 51.47 ± 1.46 years, respectively (P = 0.064), while the average mean deviation (MD) was 5.98 ± 0.66 dB and 9.79 ± 0.80 dB (P = 0.001), respectively. The frequency of mild, moderate and severe grade glaucoma in the RHE group was 47.3%, 36.5%, and 16.2%, respectively, while that in the non-RHE group was 27.6%, 31.6%, and 40.8%, respectively (P = 0.001). The presumed visual field MD progression rate for Chinese patients with untreated POAG was 0.97 dB/year. Additionally, the 24-hour IOP curve in the two groups was similar, with the exception of the IOP at 10:00 PM and 2:00 AM, which was higher in the RHE group than that in the non-RHE group. CONCLUSION: Our study showed RHE was an important and practical method to screen for POAG in Eastern China. RHE also assisted with an earlier diagnosis of POAG and may assist in preventing visual field loss.

Intraocular pressure fluctuation and the risk of glaucomatous damage deterioration: a Meta-analysis.

AIM: To systematically review whether the increased fluctuation of intraocular pressure (IOP) is a risk factor for open angle glaucoma (OAG) progression. METHODS: Scientific studies relevant to IOP fluctuation and glaucoma progression were retrieved from MEDLINE, EMBASE and CENTRAL databases, and were listed as references in this paper. The hazard ratio (HR) was calculated by using fixed or random-effects models according to the heterogeneity of included studies. RESULTS: Individual data for 2211 eyes of 2637 OAG patients in fourteen prospective studies were included in this Meta-analysis. All studies were longitudinal clinical studies with follow-up period ranging from 3 to 8.5y. The combined HR was 1.23 (95%CI 1.04-1.46, P=0.02) for the association between IOP fluctuation and glaucoma onset or progression with the evidence of heterogeneity (P<0.1). Subgroup analyses with different types of IOP fluctuation were also evaluated. Results indicated that the summary HR was 0.98 (95%CI 0.78-1.24) in short-term IOP fluctuation group, which showed no statistical significance with heterogeneity, whereas, the combined HR was 1.43 (95%CI 1.13-1.82, P=0.003) in long-term IOP fluctuation group without homogeneity. Sensitivity analysis further showed that the pooled HR was 1.10 (95%CI 1.03-1.18, P=0.004) for long-term IOP fluctuation and visual function progression with homogeneity among studies (P=0.3). CONCLUSION: Long-term IOP fluctuation can be a risk factor for glaucoma progression based on the presented evidence. Thus, controlling the swing of IOP is crucial for glaucoma or glaucoma suspecting patients.

Quantification of Visual Field Variability in Glaucoma: Implications for Visual Field Prediction and Modeling.

PURPOSE: To quantify visual field (VF) variability as a function of threshold sensitivity and location, and to compare weighted pointwise linear regression (PLR) with unweighted PLR and pointwise exponential regression (PER) for data fit and prediction ability. METHODS: Two datasets were used for this retrospective study. The first was used to characterize and estimate VF variability, and included a total of 4,747 eyes of 3,095 glaucoma patients with six or more VFs and 3 years or more of follow-up. After performing PER for each series, standard deviation of residuals was quantified for each decibel of sensitivity as a measure of variability. A separate dataset was used to test and compare unweighted PLR, weighted PLR, and PER for data fit and prediction, and included 261 eyes of 176 primary open-angle glaucoma patients with 10 or more VFs and 6 years or more of follow-up. RESULTS: The degree of variability changed as a function of threshold sensitivity with a zenith and a nadir at 33 and 11 dB, respectively. Variability decreased with eccentricity and was higher in the central 10° (P < 0.001). Differences among the methods for data fit were negligible. PER was the best model to predict future sensitivity values in the mid term and long term. CONCLUSIONS: VF variability increases with the severity of glaucoma damage and decreases with eccentricity. Weighted linear regression neither improves model fit nor prediction. PER exhibited the best prediction ability, which is likely related to the nonlinear nature of long-term glaucomatous perimetric decay. TRANSLATIONAL RELEVANCE: This study suggests that taking into account heteroscedasticity has no advantage in VF modeling.

Improving Spatial Resolution and Test Times of Visual Field Testing Using ARREST.

PURPOSE: Correctly classifying progression in moderate to advanced glaucoma is difficult. Pointwise visual field test-retest variability is high for sensitivities below approximately 20 dB; hence, reliably detecting progression requires many test repeats. We developed a testing approach that does not attempt to threshold accurately in areas with high variability, but instead expends presentations increasing spatial fidelity. METHODS: Our visual field procedure Australian Reduced Range Extended Spatial Test (ARREST; a variant of the Bayesian procedure Zippy Estimation by Sequential Testing [ZEST]) applies the following approach: once a location has an estimated sensitivity of <17 dB (a "defect"), it is checked that it is not an absolute defect (<0 dB, "blind"). Saved presentations are used to test extra locations that are located near the defect. Visual field deterioration events are either: (1) decreasing in the range of 40 to 17 dB, (2) decreasing from >17 dB to "defect", or (3) "defect" to blind. To test this approach we used an empirical database of progressing moderate-advanced 24-2 visual fields (121 eyes) that we "reverse engineered" to create visual field series that progressed from normal to the end observed field. ARREST and ZEST were run on these fields with test accuracy, presentation time, and ability to detect progression compared. RESULTS: With specificity for detecting progression matched at 95%, ZEST and ARREST showed similar sensitivity for detecting progression. However, ARREST used approximately 25% to 40% fewer test presentations to achieve this result in advanced visual field damage. ARREST spatially defined the visual field deficit with greater precision than ZEST due to the addition of non-24-2 locations. CONCLUSIONS: Spending time trying to accurately measure visual field locations that have high variability is not productive. Our simulations indicate that giving up attempting to quantify size III white-on-white sensitivities below 17 dB and using the presentations saved to test extra locations should better describe progression in moderate-to-advanced glaucoma in shorter time. TRANSLATIONAL RELEVANCE: ARREST is a new visual field test algorithm that provides better spatial definition of visual field defects in faster test time than current procedures. This outcome is achieved by substituting inaccurate quantification of sensitivities <17 dB with new spatial locations.