Association of Macular Visual Field Measurements With Glaucoma Staging Systems

Abstract

IMPORTANCE Macular function is important for daily activities but is underestimated when tested with 24-2 visual fields, which are often used to classify glaucoma severity.OBJECTIVE To test the hypothesis that current glaucoma staging systems underestimate glaucoma severity by not detecting macular damage. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study was carried out in a glaucoma referral practice. The eyes of participants with manifest glaucoma and 24-2 mean deviation (MD) better than −6 dB were included. All participants were tested with 24-2, 10-2 visual fields, and spectral-domain optical coherence tomography of the optic disc and macula.EXPOSURES Macular damage was based on the topographic agreement between visual field results and retinal ganglion cell plus inner plexiform layer probability plots. Classifications from the Hodapp-Parrish-Anderson (HPA), visual field index (VFI), and Brusini staging systems were examined and compared with visual field and spectral-domain optical coherence tomography results. MAIN OUTCOMES AND MEASURESThe association between the presence of macular damage and glaucoma severity scores.RESULTS Fifty-seven eyes of 57 participants were included; 33 participants (57%) were women, and 43 (75%) were white. Their mean (SD) age was 57 ( 14) years. Forty-eight of the eyes (84% [95% CI, 72%-92%]) had macular damage by the study definition. These had a 24-2 MD mean (SD) of −2.5 (1.8); corresponding results for the 10-2 MD were −3.0 (2.4) dB and for the VFI were 94.2% (4.5%). The HPA system classified 70% (95% CI, 55%-83%) of eyes with macular damage as having early defects; the VFI system classified 81% (95% CI, 67%-91%) of eyes with macular damage as having early defects, and the Brusini system 68% (95% CI, 53%-81%).CONCLUSIONS AND RELEVANCE These findings suggest that current glaucoma staging systems based on 24-2 (or 30-2) visual fields underestimate disease severity and the presence of macular damage. If these results are confirmed and generalizable to other participants, new systems using macular measures (from 10-2 and spectral-domain optical coherence tomography results) might improve staging of glaucoma severity.

Comparison of 10-2 and 24-2C Test Grids for Identifying Central Visual Field Defects in Glaucoma and Suspect Patients

“…21 and that in some grading systems, the presence of any central visual field defect may be regarded as advanced glaucoma, in the absence of significant mean deviation loss. 24…”

Disc Hemorrhages Are Associated With the Presence and Progression of Glaucomatous Central Visual Field Defects

“…[10][11][12][13][14][15][16][17] Thus, it appears that the presence of central VF damage, irrespective of severity of the global VF damage, may have significant implications on disease staging. 41 In addition, our previous work has demonstrated that the presence of central VF damage is predictive of global VF progression independent of baseline 24-2 mean deviation. 42 Importantly, central VF damage has been associated with poor vision-related quality of life outcomes even in early glaucoma.…”

Progressão estrutural e funcional da lesão glaucomatosa na mácula

“…(30) . Esse número é notável pois muitos dos chamados "suspeitos de glaucoma" ou "glaucoma pré-perimétrico" podem de fato apresentar lesão macular que agora os classificaria como "glaucoma grave", conforme sistemas de classificação existentes (30)(31)(32) . Com metodologia semelhante, Park et al (12) anormalidades em até 36% dos olhos com defeitos maculares (27) (35) .…”

“…Primeiro, conforme demonstrado por vários autores utilizando-se dados transversais (12,13,28) , incluindo-se estudos realizados por De Moraes e colaboradores que serviram de premissa para o presente estudo (8,11,26,27,31) , o uso exclusivo de perimetria acromática 24-2 e OCT de CFNR peripapilar pode levar a não detecção de dano funcional e estrutural na mácula. Por exemplo, De Moraes et al (31) demonstraram que a perimetria 24-2 pode não detectar lesão funcional e estrutural na mácula em até 70% dos pacientes considerados suspeitos de glaucoma ou portadores de glaucoma inicial. A detecção de dano funcional central nesses pacientes não só altera seu diagnóstico (de suspeito ou pré-perimétrico para glaucoma manifesto), como também os classifica como tendo defeito avançado (30) , com provável impacto em sua qualidade de vida (18)(19)(20) .…”

“…Outro ponto de importância é que, tanto o presente projeto (análise de progressão) como o trabalho anterior de De Moraes e colaboradores (focado no diagnóstico) (8,11,27,31) não visam a substituir as medidas convencionais de estrutura (CFNR peripapilar) e função (perimetria 24-2 Outra informação relevante descrita no presente estudoe consistente com a literaturaé que a maior parte dos pacientes com ou suspeitos de glaucoma progridem a taxas lentas quando tratados adequadamente (42,101) . Usando-se o MD do 24-2, por exemplo, a taxa de progressão foi menor que -0,20 dB/ano na maioria dos pacientes.…”