Detection of asymmetric glaucomatous damage using automated pupillography, the swinging flashlight method and the magnified-assisted swinging flashlight method

Abstract

Purpose To determine the sensitivity and specificity of various methods of detecting a relative afferent pupillary defect (RAPD) in patients with glaucoma-related diagnoses. Patients and methods Patients underwent RAPD evaluation using the swinging flashlight method (SFM), the magnifier-assisted SFM, and pupillography using the Konan RAPDx. Main outcome measures were sensitivity and specificity of three methods of RAPD evaluation in detecting visual field mean deviation (MD), cup to disc ratio (CDR), disc damage likelihood scale (DDLS), and retinal nerve fiber layer (RNFL) asymmetry. Results Eighty-one consecutive patients from the Wills Eye Hospital glaucoma service were enrolled, 60 with glaucoma and 21 with ocular hypertension or glaucoma suspect. Thirty-one percent of subjects had MD asymmetry45 dB, 19.7% had CDR asymmetry ≥ 0.20, 26.7% had DDLS asymmetry ≥ 2, and 38.2% had RNFL asymmetry410 microns. Sensitivity values for pupillography were 93.3% (95% CI, 68.1-99.8) for detecting MD asymmetry, 80.0% (95% CI, 51.9-95.7) for CDR asymmetry, 100.0% (95% CI, 73.5-100.0) for DDLS asymmetry, and 69.2% (95% CI, 38.6-90.9) for RNFL asymmetry. Specificity values were 41.2% (95% CI, 24.7-59.3) for detecting MD asymmetry, 32.8% (95% CI, 21.3-46.0) for CDR asymmetry, 33.3% (95% CI, 18.0-51.8) for DDLS asymmetry, and 42.9% (95% CI, 21.8-66.0) for RNFL asymmetry.Pupillography amplitude score was correlated with MD asymmetry (r 2 = 0.41, Po0.001) and area under the curve was 0.84. Conclusion Automated pupillography had higher sensitivity and lower specificity in detecting MD, CDR, DDLS, and RNFL asymmetry. Within the bounds of the cohort tested, this method had limited case-finding ability.

Effects of Age and Sex on Values Obtained by RAPDx®Pupillometer, and Determined the Standard Values for Detecting Relative Afferent Pupillary Defect

“…In our previous study, we found that the data obtained by the RAPDx ® pupillometer were valid, reproducible, and reliable. 3 This instrument has been used to determine whether RAPD was present in patients with glaucoma, 4 – 9 amblyopia, 10 and optic nerve diseases. 11 However, there have not been any studies determining the standard values of the amplitude and latency scores of the RAPDx ® pupillometer in healthy eyes.…”

Evaluating State-of-the-Art Computerized Pupillary Assessments for Glaucoma Detection: A Systematic Review and Meta-Analysis

“…The average age of the glaucoma participants ranged from 49 to 78 years; the average age of the healthy participants ranged from 35 to 84 years. Thirteen studies enrolled patients with glaucoma of any cause in at least one eye, defined as having both optic disc or RNFL structural abnormalities and visual field defects consistent with structural damage or glaucomatous defects ( 7 , 15 – 17 , 21 , 25 , 28 – 33 , 37 ); 11 studies enrolled patients with primary open angle glaucoma (POAG) ( 13 , 14 , 18 , 22 , 24 , 26 , 27 , 32 , 34 – 36 ); One study enrolled POAG patients as well as PACG patients ( 20 ).…”

“…For the shape pattern stimulus, 15 studies used full-field illumination paradigms ( 7 , 14 , 15 , 18 , 20 – 22 , 24 , 25 , 28 , 31 , 33 – 35 , 37 ), 10 studies used regional illumination paradigms ( 7 , 15 , 20 , 22 , 24 , 25 , 27 – 29 , 31 ), and six studies assessed the visual field defects by functionally-shaped stimuli (e.g., multifocal, Paracentral/Bjerrum/Peripheral) ( 13 , 23 , 26 , 30 , 32 , 36 ). For dark adaptation before stimuli, the dark adaptation time of 11 studies was between 1 and 2 min ( 14 , 15 , 17 , 18 , 20 , 21 , 25 , 28 , 31 , 33 , 34 ). The other four studies performed 15 s ( 22 , 24 ), 5 min ( 30 ), and 10 min of dark adaptation ( 35 ).…”

“…Table S3 summarizes a detailed description of CPLRADs. Nine studies employed white stimuli in the standard examination ( 13 , 18 , 21 – 24 , 30 , 31 , 33 ); 14 studies used colored stimuli (red and/or green and/or yellow and/or blue and/or white) ( 7 , 14 – 17 , 20 , 25 , 27 , 29 , 32 , 34 – 37 ). Sixteen studies assessed the between-eye pupillary response (i.e., the RAPD test) ( 7 , 13 , 15 , 16 , 18 , 20 – 22 , 24 – 26 , 28 , 29 , 31 , 32 , 36 ), and 12 studies evaluated the performance of the unilateral PLR test ( 7 , 14 , 17 , 23 , 25 , 27 , 28 , 30 , 33 – 35 , 37 ).…”

Evaluation of Relative Afferent Pupillary Defect Using RAPDx Device in Patients with Optic Nerve Disease

“…The parameters of amplitude score and latency score in RAPDx are used to calculate RAPD using log units; the amplitude score is obtained by determining the percentage of constriction of both eyes, whereas the latency score is obtained by determining the latency of both eyes. Many investigators have used the RAPDx to evaluate glaucoma, [5][6][7][8][9][10] amblyopia, 11 and optic nerve disease, 12 but standard values for detection of RAPD using this device are still not available.…”