Section 1 – Visual function progression
- Standard white-on-white automated perimetry (SAP), with a fixed testing matrix covering at least the central 24 degrees, is preferred for measuring progression in eyes with glaucomatous VF loss.
Comment: more research is needed into the use of alternative measures of visual function (FDP, resolution perimetry, motion perimetry and others) to detect glaucomatous progression, before any of these can be considered alternatives to SAP for measuring progression.
Comment: It is possible for glaucomatous optic neuropathy to progress structurally in the absence of functional progression and vice-versa.
- Perform sufficient examinations to detect change.
Comment: decisions on progression should not be made by comparing only the most recent field with the one before.
Comment: suspected progression should be confirmed by repeating the field.
Baseline data collection (no previous VFs available) – first two years
- In clinical practice, at least two reliable VFs is optimal in the first six months.
Comment: In clinical scenarios, where the lifetime risk of visual disability is high, such as those who already have advanced damage, three baseline VFs may be necessary.
Comment: A good baseline of reliable VFs is essential to be able to monitor for progression.
Comment: Unless there are obvious learning effects, high false-positive errors, rim artifacts, or other obvious artifacts, examinations should not be removed from the analyses.
- At least two further VFs should be performed within the next 18 months.
- VF testing should be repeated sooner than scheduled if possible progression is identified on the basis of an ‘event’ analysis.
Comment: In patients at risk of visual disability, performing six VFs in the first two years enables the clinician to rule out rapid progression (2 dB/year or worse) and establishes an ideal set of baseline data.
Comment: the identification of possible progression may be on the basis of an ‘event’ criterion such as the Glaucoma Progression Analysis (in the Humphrey perimeter software) or ‘Nonparametric Progression Analysis’.
- Establish a new baseline after a significant therapeutic intervention (e.g., surgery). Comment: the new baseline can be the last fields that defined the previous progression ‘event’.
Follow-up data collection (after the initial two years)
- The frequency of follow-up VFs should be based on the risk of clinically significant progression (based on extent of damage and life expectancy).
- In low and moderate risk patients, subsequent VF frequency should be one VF per year (unless there is a long follow-up) and, as a rule, repeated sooner if possible. Progression is identified on the basis of an ‘event’ analysis, or if other clinical observations are suggestive of possible progression or increased risk of progression.
Comment: relevant clinical observations include structural progression (clinically noted or measured by imaging), a splinter hemorrhage, or inadequate IOP control.
- In high risk patients, subsequent VF frequency should be two VFs per year and repeated sooner if possible progression is identified on the basis of an ‘event’ analysis, or if other clinical observations are suggestive of progression or increased risk of progression.
Comment: following confirmed progression (by an ‘event’), the frequency of testing should be based on the estimated rate of progression, risk factors and other clinical indicators of progression, stage of disease and life expectancy.
Comment: patients who have been stable for a long period, or who are progressing so slowly as to be at little risk for reaching disabling levels of field loss, and other clinical parameters indicate low risk of progression, may have VF testing less frequently than 1 VF per year.
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