Diagnostic test accuracy of the pattern electroretinogram for glaucoma: a systematic review and meta-analysis

The pattern electroretinogram (PERG) has been investigated as a potential functional biomarker for detecting retinal ganglion cell dysfunction in glaucoma. However, reported diagnostic performance appears to vary across disease stages and recording protocols. This systematic review and meta-analysis aimed to evaluate the diagnostic accuracy of PERG for glaucoma.

PubMed, Embase, and Web of Science were comprehensively searched up to March 2025. Studies assessing PERG accuracy against a clinical reference standard were included. Risk of bias was assessed using QUADAS-2. Data were synthesized using a hierarchical summary receiver operating characteristic model. Subgroup analyses were performed based on disease severity and International Society for Clinical Electrophysiology of Vision-standardized protocols. Sources of heterogeneity were explored through sensitivity analyses.

Twenty-one studies involving 1 793 participants (2 580 eyes) were analyzed. Pooled sensitivity and specificity for manifest glaucoma were 0.79 (95% CI: 0.76-0.82) and 0.78 (95% CI: 0.75-0.80), respectively. Diagnostic performance for glaucoma suspects was comparable. The ocular hypertension subgroup exhibited moderate pooled sensitivity (0.54) with considerable heterogeneity. Sensitivity analysis suggested that this variation might stem from the higher sensitivity of the Hemifield protocol compared with standard full-field stimulation. Regarding temporal frequency, transient PERG appeared to demonstrate marginally higher diagnostic estimates than steady-state protocols.

Current literature affirms the clinical viability of PERG; however, inconsistent performance metrics in the preperimetric phase suggest that standard full-field configurations may lack the requisite sensitivity to capture incipient localized damage. Preliminary findings suggest that protocol optimization-potentially involving Hemifield stimulation-may offer advantages for detecting early functional loss, warranting further validation in future studies.