To determine the rate of glaucomatous visual field change in routine clinical care.
Mean deviation (MD) rate was computed in one randomly selected eye of all glaucoma patients and suspects with ≥5 ...examinations in a tertiary eye-care center. Proportions of "fast" (MD rate, <-1 to -2 dB/y) and "catastrophic" (<-2 dB/y) progressors were determined. The MD rates were computed in tertile groups by the number of examinations, baseline age, and MD. The MD rates were compared to the Canadian Glaucoma Study (CGS), a prospective study with IOP interventions mandated by visual field progression, by pairwise matching of patients by baseline MD.
There were 2324 patients with median (interquartile range) baseline age and MD of 65 (56, 74) years and -2.44 (-5.44, -0.86) dB, and follow-up of 7.1 (4.8, 10.2) years with 8 (6, 11) examinations. The median MD rate was -0.05 (0.13, -0.30) dB/y, while the mean follow-up IOP was 17.1 (15.0, 19.7) mm Hg. The MD rate was progressively worse, with a doubling of fast and catastrophic progressors, with each tertile of increasing age. Worse MD rate was associated with lower follow-up IOP. Neither MD rate nor the number of fast and catastrophic progressors was significantly different in clinical care patients matched to CGS patients.
Most patients under routine glaucoma care demonstrate slow rates of visual field progression. The MD rate in the current study was similar to an interventional prospective study, but considerably less negative compared to published studies with similar design.
To determine the response of the anterior lamina cribrosa and prelaminar tissue to acute elevation of intraocular pressure (IOP) in glaucoma patients and healthy subjects.
Prospective case-control ...series.
Patients with open-angle glaucoma (n = 12; mean age ± standard deviation SD, 66.8 ± 6.0 years), age-matched healthy controls (n = 12; mean age ± SD, 67.1 ± 6.2 years), and young controls (n = 12; mean age ± SD, 36.1 ± 11.7 years).
One eye was imaged with spectral-domain optical coherence tomography to obtain 12 high-resolution radial scans centered on the optic disc. Imaging was repeated at precisely the same locations with an ophthalmodynamometer held perpendicular to the globe via the inferior lid to raise the IOP. A line joining Bruch's membrane opening in 4 radial scans was used as reference in the baseline and elevated IOP images. The vertical distance from the reference line to the anterior prelaminar tissue surface and anterior laminar surface was measured at equidistant points along the reference line in the 2 sets of images. The difference between the 2 sets of corresponding measurements were used to determine laminar displacement (LD) and prelaminar tissue displacement (PTD).
Laminar displacement and PTD.
Intraocular pressure elevation among patients, age-matched controls, and young controls was similar (mean ± SD, 12.4 ± 3.2 mmHg). The mean ± SD LD and PTD were 0.5 ± 3.3 μm and 15.7 ± 15.5 μm, respectively. The LD was not statistically different from 0 (P = 0.366), but PTD was (P < 0.001). The mean ± SD LD was similar among the groups (-0.5 ± 3.7 μm, 0.2 ± 2.0 μm, and 2.0 ± 3.6 μm, respectively; P = 0.366), whereas the mean ± SD PTD was different (6.8 ± 13.7 μm, 20.8 ± 17.5 μm, and 19.6 ± 11.8 μm, respectively; P = 0.045). In all subjects, the PTD was greater than LD. In multivariate regression analyses, LD was negatively associated with optic disc size (P = 0.007), whereas PTD was positively associated with the degree of IOP elevation (P = 0.013).
In glaucoma patients and controls, the anterior laminar surface is noncompliant to acute IOP elevation. Acute optic disc surface changes represent compression of prelaminar tissue and not laminar displacement.
It has been shown that threshold estimates below approximately 20 dB have little effect on the ability to detect visual field progression in glaucoma. We aimed to compare stimulus size V to stimulus ...size III, in areas of visual damage, to confirm these findings by using (1) a different dataset, (2) different techniques of progression analysis, and (3) an analysis to evaluate the effect of censoring on mean deviation (MD).
In the Iowa Variability in Perimetry Study, 120 glaucoma subjects were tested every 6 months for 4 years with size III SITA Standard and size V Full Threshold. Progression was determined with three complementary techniques: pointwise linear regression (PLR), permutation of PLR, and linear regression of the MD index. All analyses were repeated on "censored'' datasets in which threshold estimates below a given criterion value were set to equal the criterion value.
Our analyses confirmed previous observations that threshold estimates below 20 dB contribute much less to visual field progression than estimates above this range. These findings were broadly similar with stimulus sizes III and V.
Censoring of threshold values < 20 dB has relatively little impact on the rates of visual field progression in patients with mild to moderate glaucoma. Size V, which has lower retest variability, performs at least as well as size III for longitudinal glaucoma progression analysis and appears to have a larger useful dynamic range owing to the upper sensitivity limit being higher.
To establish a method for estimating the overall statistical significance of visual field deterioration from an individual patient's data, and to compare its performance to pointwise linear ...regression.
The Truncated Product Method was used to calculate a statistic S that combines evidence of deterioration from individual test locations in the visual field. The overall statistical significance (P value) of visual field deterioration was inferred by comparing S with its permutation distribution, derived from repeated reordering of the visual field series. Permutation of pointwise linear regression (PoPLR) and pointwise linear regression were evaluated in data from patients with glaucoma (944 eyes, median mean deviation -2.9 dB, interquartile range: -6.3, -1.2 dB) followed for more than 4 years (median 10 examinations over 8 years). False-positive rates were estimated from randomly reordered series of this dataset, and hit rates (proportion of eyes with significant deterioration) were estimated from the original series.
The false-positive rates of PoPLR were indistinguishable from the corresponding nominal significance levels and were independent of baseline visual field damage and length of follow-up. At P < 0.05, the hit rates of PoPLR were 12, 29, and 42%, at the fifth, eighth, and final examinations, respectively, and at matching specificities they were consistently higher than those of pointwise linear regression.
In contrast to population-based progression analyses, PoPLR provides a continuous estimate of statistical significance for visual field deterioration individualized to a particular patient's data. This allows close control over specificity, essential for monitoring patients in clinical practice and in clinical trials.
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•Do letter biases affect visual performance in letter acuity tasks?•Re-analysis and modelling of Sloan letter recognition as a function of size.•Model assumes letter templates, each ...with a different bias, plus noise.•Template biases were consistent across letter sizes, varying between subjects.•Sensitivity variation between templates was less important than bias.
In clinical testing of visual acuity, it is often assumed that performance reflects sensory abilities and observers do not exhibit strong biases for or against specific letters, but this assumption has not been extensively tested. We re-analyzed single-letter identification data as a function of letter size, spanning the resolution threshold, for 10 Sloan letters at central and paracentral visual field locations. Individual observers showed consistent letter biases across letter sizes. Preferred letters were named much more often and others less often than expected (group averages ranged from 4% to 20% across letters, where the unbiased rate was 10%). In the framework of signal detection theory, we devised a noisy template model to distinguish biases from differences in sensitivity. When bias varied across letter templates the model fitted very well - much better than when sensitivity varied without bias. The best model combined both, having substantial biases and small variations in sensitivity across letters. The over- and under-calling decreased at larger letter sizes, but this was well-predicted by template responses that had the same additive bias for all letter sizes: with stronger inputs (larger letters) there was less opportunity for bias to influence which template gave the biggest response. The neural basis for such letter bias is not known, but a plausible candidate is the letter-recognition machinery of the left temporal lobe. Future work could assess whether such biases affect clinical measures of visual performance. Our analyses so far suggest very small effects in most settings.
Properties of the statpac visual field index Artes, Paul H; O'Leary, Neil; Hutchison, Donna M ...
Investigative ophthalmology & visual science,
2011-Jun-08, Letnik:
52, Številka:
7
Journal Article
Recenzirano
Odprti dostop
Purpose. To compare the properties of the visual field index (VFI) to those of mean deviation (MD) in patients with glaucoma. Methods. MD and VFI were calculated in data obtained from an ongoing ...longitudinal study in which patients with glaucoma (N = 109, 204 eyes) were observed for 9.8 years (median, 21 tests) with static automated perimetry. MD and VFI were compared in one test of each eye, and a subset of 30 tests were selected to compare the VFI with the judgments of eight experts who judged the percentage of the remaining visual field. In series of tests obtained over time, rates of change, statistical significance, evidence of nonlinearity, and variability were compared between both indices. Results. In single tests, MD and VFI were closely related (r = 0.88, P < 0.001). The relationship between both indices appeared linear, except in visual fields with MDs better than -5.0 dB where 29 (22%) of 129 eyes exhibited a ceiling effect (VFI = 100%). Based on this relationship, the predicted VFIs for visual fields with MDs of -5, -10, and -15 dB were 91%, 76%, and 60%, respectively. The percentage of remaining visual field suggested by the VFI exceeded the range of the experts' subjective judgments in 16 (53%) of 30 eyes. In series of tests obtained over time, rates of change with the two indices were closely related (r = 0.79, P < 0.001), and statistically significant reductions over time (P < 0.05) occurred in a similar number of eyes (92 45% with MD, and 87 43% with VFI). Of the 105 eyes with statistically significant (P < 0.05) negative trend in either MD or VFI, 74 (70%) showed such trends with both indices (κ = 0.69). The variability of MD and VFI increased with damage, and there was no evidence that change over time was more linear with VFI than with MD. Conclusions. The VFI provides a simple and understandable metric of visual field damage, but its estimates of remaining visual field were more optimistic than those of the experts. Rates of change over time with both indices were closely related, but the reliance of the VFI on pattern deviation probability maps caused a ceiling effect that may have reduced its sensitivity to change in eyes with early damage. In this group of patients there was no evidence to suggest that the VFI is either superior or inferior to the MD as a summary measure of visual field damage.
To estimate the specificity of the Guided Progression Analysis (GPA) (Carl Zeiss Meditec, Dublin, CA) in individual patients with glaucoma.
Observational cohort study.
Thirty patients with open-angle ...glaucoma.
In 30 patients with open-angle glaucoma, 1 eye (median mean deviation MD, -2.5 decibels dB; interquartile range, -4.4 to -1.3 dB) was tested 12 times over 3 months (Humphrey Field Analyzer, Carl Zeiss Meditec; SITA Standard, 24-2). "Possible progression" and "likely progression" were determined with the GPA. These analyses were repeated after the order of the tests had been randomly rearranged (1000 unique permutations).
Rate of false-positive alerts of "possible progression" and "likely progression" with the GPA.
On average, the specificity of the GPA "likely progression" alert was high-for the entire sample, the mean rate of false-positive alerts after 10 follow-up tests was 2.6%. With "possible progression," the specificity was considerably lower (false-positive rate, 18.5%). Most important, the cumulative rate of false-positive alerts varied substantially among patients, from <1% to 80% with "possible progression" and from <0.1% to 20% with "likely progression." Factors associated with false-positive alerts were visual field variability (standard deviation of MD, Spearman's rho = 0.41, P<0.001) and the reliability indices (proportion of false-positive and false-negative responses, fixation losses, rho>0.31, P≤0.10).
On average, progression criteria currently used in the GPA have high specificity, but some patients are more likely to show false-positive alerts than others. This is a natural consequence of population-based change criteria and may not matter in clinical trials and studies in which large groups of patients are compared. However, it must be considered when the GPA is used in clinical practice where specificity needs to be controlled for individual patients.
The nature and mode of functional and structural progression in open-angle glaucoma is a subject of considerable debate in the literature. While there is a traditionally held viewpoint that optic ...disc and/or nerve fibre layer changes precede visual field changes, there is surprisingly little published evidence from well-controlled prospective studies in this area, specifically with modern perimetric and imaging techniques. In this paper, we report on clinical data from both glaucoma patients and normal controls collected prospectively over several years, to address the relationship between visual field and optic disc changes in glaucoma using standard automated perimetry (SAP), high-pass resolution perimetry (HRP) and confocal scanning laser tomography (CSLT). We use several methods of analysis of longitudinal data and describe a new technique called “evidence of change” analysis which facilitates comparison between different tests. We demonstrate that current clinical indicators of visual function (SAP and HRP) and measures of optic disc structure (CSLT) provide largely independent measures of progression. We discuss the reasons for these findings as well as several methodological issues that pose challenges to elucidating the true structure–function relationship in glaucoma.
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