A Staged Approach to the Number and Frequency of Visual Field Testing for Detecting Glaucoma Progression

To assess a staged visual field review model (initially intensive, then downtitrated) for detecting cases of glaucoma progression (especially catastrophic and fast), in comparison to clinical standard, fixed review approaches.

A computer simulation study.

A total of 100 000 subjects.

A total of 100 000 subjects were simulated to undergo 4 visual field tests in 1 "eye" per visit, every 3 months, over 30 years. The staged visual field model consisted of an initial intensive review (e.g., 3 tests per eye per visit, every 3 months) that was then downtitrated as 90% of progressors within a rate bin (e.g., catastrophic <-2 dB/year) were detected. The test number and review cadence were systematically downtitrated with 90% of successive progression-rate bins detected until the end of the 30-year follow-up. Comparator models were fixed reviews: 1 test every 12 months, 1 test every 6 months, 2 tests every 6 months ("frontloading"), and 3 tests every 24 months ("wait-and-see"). To reduce false positives, an immediate subsequent confirmatory progression result was required for all conditions.

Number of progressors detected and number of tests/visits required per case of progression detected.

All staged review approaches detected 90% of catastrophic (21-36 months) and fast (36-60 months) progression bins sooner compared to all fixed methods (catastrophic: 66-108 months; fast: 84-132 months) except fixed frontloading. Detection of 50% of all progressors was also achieved sooner for the staged approaches (21-36 months) compared to all fixed methods (60-96 months), except for fixed frontloading (36 months). When using 1 test every 12 months as a reference standard, the staged approaches were 66% to 251% more likely to detect progression. The 2 tests per visit at every 3 and 6 months staged intervals were the most efficient with the lowest number of visits (10.6 and 8.6 at 5 years) and tests (15.8 and 12.9 at 5 years) per case detected over time.

A staged visual field review model starting with intensive testing (such as 2 tests per visit at every 3 or 6 months intervals) with downtitration at 30-36 months may increase the likelihood of detecting progressors and may provide long-term efficiencies in case detection, in comparison to conventional fixed approaches.

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.