CLINICAL Early DetectionGUIDELINES Saves Sight

Edition 3 :: April 2012

An initiative of Guide Dogs NSW/ACT and The University of New South Wales

VISUAL FIELD STAGING AND PROGRESSION

Perimetry, a technique of assessing a persons visual field (VF), is important in the diagnosis of glaucoma, and as a means of determining progression of glaucomatous damage. VF loss may precede, be concurrent with, or follow, optic nerve damage in the early stages of glaucoma. Once diagnosed, perimetry is considered the gold standard for monitoring glaucoma progression. It is therefore important to use a consistent examination strategy when repeating VF tests. Standard white-on-white automated perimetry (SAP), an extensively researched and well-established technique to quantify VF sensitivity,1 is considered the reference standard for VF examination of patients with glaucoma. SAP, with a fixed testing matrix of at least the central 24 degrees, is recommended. Literature on progression analysis is only available for white-on-white SAP, and it therefore remains the gold standard for measuring progression.1 Research into VF progression by alternative measures, such as frequency doubling perimetry (FDT) and motion perimetry, is needed. The role of FDT perimetry in the diagnosis and management of glaucoma is yet to be defined adequately, and there is currently no compelling evidence to support the replacement of SAP2. By clearly defining the stages of disease, the effectiveness of treatment at each stage can be better assessed (Table 2). glaucoma to diagnosed glaucoma. To flag progression, confirmed deterioration is required with consecutive tests. Focal / regional metrics show the location of the progression, while summary/global metrics show the overall progression over time. Glaucoma Change Probability is a form of event analysis which is commercially available with the Statpac program of the HVFA. Manual detection can also be used. For example, the progression from Stage 0 to Stage 1 is an event determined by examining for changes in global indices and local depressions, expressed in probability values (Table 2). According to guidelines by the (previous) Optometrists Registration Board of Victoria (ORBV)7, at least four or five VF tests may be required to establish stability/progression (Table 3). Practitioners need to show at least twice that an unaffected area is now affected, or has definitely changed. Therefore, two fields are needed to establish baseline and two are needed to confirm progression. Practitioners monitoring advanced glaucoma or low tension glaucoma will need to use a test pattern that can identify threats to fixation. Event analyses generally detect progression earlier than trend analysis. Trend analysis Trend analysis is used to measure/quantify progression. It is usually performed by measuring the rate of change in a visual field index, typically mean deviation (MD) over time.

Frequency of testing5
VF results can be impacted by inherent variabilities and patient learning curves. At least 2-3 VF tests should be conducted in the first year after glaucoma diagnosis to accommodate patient learning. The best of these early tests should be used as the baseline. More frequent testing may be required depending on the patients clinical risk factors for progression, or if a significant change is suspected.

Detection of progression1,5
Major clinical trials, such as OHTS (Ocular Hypertension Treatment Study6), require two baseline and three abnormal VFs, with the last taking place within 8 weeks of the second failed test (using HVFA results that meet reliability criteria). The criteria for progression from normal to glaucomatous are: GHT (Glaucoma Hemifield Test) at P<0.03. Therefore borderline at P<0.03 or outside normal limits at P<0.01 are both fail criteria; and/or Corrected Pattern Standard Deviation (CPSD) at P<0.05.

Event analysis and trend analysis are the two main approaches to identifying VF changes. Event analysis Event analysis detects progression and is usually performed by comparing followup fields with baseline fields. It is useful for detecting conversion of suspected

Grading glaucoma
The use of a standard classification of glaucoma severity can promote clear communication between health care providers. The continuum of glaucoma severity can be graded by VF results (Table 1)3. These grading scales are based on the Humphrey Visual Field Analyser (HVFA).

TABLE 1: A CONTINUUM OF GLAUCOMA SEVERITY BASED ON VISUAL FIELDS

No glaucomatous impairment Mild glaucoma Moderate glaucoma Severe glaucoma

No VF defects Glaucoma suspect Unilateral VF defect Receiving treatment Up to five missed points (<10 dB mean deviation or average loss) in binocular central 20 of VF Six adjoining missed points (<10 dB) and any additional separate missed point(s), or a cluster of four adjoining missed points (<10 dB), either of which is wholly or partly within the central 20 superior or inferior hemifield.

Glaucoma Staging System (GSS)

GSS is a method of measuring glaucoma progression, in patients already diagnosed, using the HVFA4.

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This type of analysis allows for easier prediction of the time to reach severe visual loss. The ability to detect a given rate of visual field change expressed in MD/year depends on the variability of MD over time, the number of examinations and the amount of change to detect. Table 4 illustrates time (in years) to detect various rates of MD change with

In general, rate-based analyses are used later in the follow-up, when a greater number of VFs are available over a sufficient period of time to measure the rate of progression. Additional computer software and analysis of the regression is required for trend analysis, such as the Glaucoma Progression Analysis (GPA) software on the HVFA.

80% power in visual fields with low, moderate and high variability10. In a reliable patient (low variability of MD) with two annual VF exams, it would take three years to detect an annual progression of -1.00 dB in MD. As a general rule, 0 to -0.5 dB/year is considered no or minimal progression; >-0.5 dB/year to <-1.5 dB/year is moderate and >-1.5 dB/year is high progression.

TABLE 2: GLAUCOMA STAGING SYSTEM (GSS) DEFINITIONS AND SEVERITY CRITERIA

Stage Stage 0: No or Minimal Defect Stage 1: Early Defect

Humphrey MD Score

Additional Criteria (at least one of the listed criteria must apply)

TABLE 4: TIME REQUIRED TO DETECT VARIOUS RATES OF MEAN DEVIATION (MD) PROGRESSION

Progression rate (dB/year) -6.00 dB A cluster of 3 points on the pattern deviation plot in an expected location of the visual field depressed below the 5% level, at least one of which is depressed below the 1% level. CPSD/PSD significant at P<0.05 GHT outside normal limits 25% but < 50% of points on the pattern deviation plot depressed below the 5% level, and 15% but < 25% of points depressed below the 1% level At least 1 point within the central 5 with sensitivity of < 15 dB but no points in the central 5 with sensitivity of < 0 dB Only 1 hemifield containing a point with sensitivity < 15 dB within 5 of fixation 50% but < 75% of points on pattern deviation plot depressed below the 5% level and 25% but < 50% of points depressed below the 1% level Any point within the central 5 with sensitivity <0 dB Both hemifields containing a point(s) with sensitivity < 15 dB within 5 of fixation 75% of points on pattern deviation plot depressed below the 5% level and 50% of points depressed below the 1% level At least 50% of points within the central 5 with sensitivity < 0 dB Both hemifields containing > 50% of points with sensitivity < 15 dB within 5 of fixation One exam per year -0.25 -0.50 -1.00 -2.00 Two exams per year -0.25 -0.50 -1.00 -2.00 Three exams per year -0.25 -0.50 -1.00 -2.00

Variability of MD Low Moderate High

Years to progress 13.0* 9.0 6.0 5.0 19.0 13.0 9.0 6.0 30.0 19.0 13.0 9.0

Stage 2: Moderate Defect -6.01 to -12.00 dB

Stage 3: Advanced Defect -12.01 dB to -20.00 dB

Years to progress 6.5 4.5 3.0 2.5 8.5 6.5 4.5 3.0 15.0 8.5 6.5 4.5

Years to progress 4.3 3.0 2.0 1.7 6.3 4.3 3.0 2.0 10.0 6.3 4.3 3.0

Stage 4: Severe Defect -20.00 dB Stage 5: End-Stage Disease

This edition prepared by Carol Chu, Staff Optometrist. References available online at cfeh.com.au/clinical-guidelines. Although every care is taken by CFEH to ensure that this document is free from any error or inaccuracy, CFEH does not make any representation or warranty regarding the currency, accuracy or completeness of these Guidelines. Printed June 2012.

Unable to perform HVFA in worst eye due to central scotoma OR worst eye VA 6/60 or worse due to POAG. Fellow eye may be at any stage.

TABLE 3: GUIDELINES FROM THE OPTOMETRISTS REGISTRATION BOARD OF VICTORIA*

Initial VF 10 dB loss in three adjacent points 10 dB loss in three adjacent points

Action Test again in 2-6 weeks Test again in 2-6 weeks

Followup VF 3 x 15 dB loss 3 x 10-15 dB loss

Action Consult with ophthalmologist Test again every 6-12 weeks until worsens or improves Consult ophthalmologist (evidence of progression) Consult ophthalmologist (evidence of progression)

Repeatable loss in a previously normal field, 3 points each with >10 dB Two neighbouring points adjacent to an existing scotoma that decline by more than 10 dB.

* In 2010 the ORBV integrated with the Optometry Board of Australia. These guidelines are similar to those of the Collaborative Normal Tension Glaucoma Study (CNTGS)8 and Clinical Scoring System (CSS)9.

Ask your patients affected by glaucoma to contact Glaucoma Australia for information and support. www.glaucoma.org.au / (02) 9906 6640

CLINICAL Early DetectionGUIDELINES Saves Sight

Edition 3 :: April 2012
An initiative of Guide Dogs NSW/ACT and The University of New South Wales

References
1. Weinreb RN, Garway-Heath DF, Leung C, et al. Progression of glaucoma. Amsterdam: Kugler Publications 2011. 2. Jampel HD, Singh K, Lin SC, et al. Assessment of visual function in glaucoma. Ophthalmol 2011; 118:986-1002. 3. Burr JM, Mowatt G, Hernandez R, et al. The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation. Health Tech Assess 2007; 11:1-206. 4. Mills RP, Budenz DL, Lee PP, et al. Categorizing the stage of glaucoma from pre-diagnosis to end-stage disease. Am J Ophthalmol 2006; 141:24-30. 5. NHMRC Guidelines for the screening, prognosis, diagnosis, management and prevention of glaucoma (2010). Canberra: Australian Government Publisher. 6. Keltner JL, Johnson CA, Quigg JM, et al. Confirmation of visual field abnormalities in the Ocular Hypertension Treatment Study. Arch Ophthalmol 2000;118:1187-1197. 7. Optometrists Registration Board Victoria (ORBV). Protocols and guidelines for therapeutic drug use by endorsed optometrists. August 2003. (Available upon request) 8. CNTG Study Group. Comparison of glaucomatous progression between untreated patients with normal tension glaucoma and patients with therapeutically reduced intraocular pressures. Am J Ophthal 1998; 126:487-497 9. Girkin CA, Emdadi A, Sample PA, et al. Short-wavelength automated perimetry and standard perimetry in the detection of progression of optic disc cupping. Arch. Ophthalmol 2000; 118:1231-1236. 10. Chauhan BC, Garway-Heath DF, Goni FJ, et al. Practical recommendations for measuring rates of visual field change in glaucoma. Br J Ophthalmol 2008; 92:569-573.