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Original Investigation
January 2, 2020

Characterization of Central Visual Field Loss in End-stage Glaucoma by Unsupervised Artificial Intelligence

Author Affiliations
  • 1Schepens Eye Research Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston
  • 2Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
  • 3Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, the Netherlands
  • 4Eye and Vision Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York
  • 5Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 6Massachusetts Eye and Ear, Harvard Medical School, Boston
  • 7Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 8Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida
  • 9Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, New York
  • 10Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
  • 11Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham
  • 12Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore
  • 13Institute for Psychology and Behavior, Jilin University of Finance and Economics, Changchun, China
  • 14Department of Psychology, Northeastern University, Boston, Massachusetts
  • 15Max Planck Institute for Mathematics in the Sciences, Leipzig, Germany
JAMA Ophthalmol. Published online January 2, 2020. doi:10.1001/jamaophthalmol.2019.5413
Key Points

Question  What are the typical patterns of central visual field loss in end-stage glaucoma, and do deteriorations follow trajectories specific to their baseline patterns?

Findings  In this cohort study of 1103 patients with glaucoma, 14 central visual field patterns were determined by archetypal analysis, most of which preserve the inferotemporal regions entirely or partially. Initial encroachments on an intact central visual field at follow-up in end-stage glaucoma were more likely to be nasal loss.

Meaning  These results suggest that central visual field loss in end-stage glaucoma exhibits characteristic patterns that might be related to different subtypes, and initial central visual field loss is likely to be nasal loss.


Importance  Although the central visual field (VF) in end-stage glaucoma may substantially vary among patients, structure-function studies and quality-of-life assessments are impeded by the lack of appropriate characterization of end-stage VF loss.

Objective  To provide a quantitative characterization and classification of central VF loss in end-stage glaucoma.

Design, Setting, and Participants  This retrospective cohort study collected data from 5 US glaucoma services from June 1, 1999, through October 1, 2014. A total of 2912 reliable 10-2 VFs of 1103 eyes from 1010 patients measured after end-stage 24-2 VFs with a mean deviation (MD) of −22 dB or less were included in the analysis. Data were analyzed from March 28, 2018, through May 23, 2019.

Main Outcomes and Measures  Central VF patterns were determined by an artificial intelligence algorithm termed archetypal analysis. Longitudinal analyses were performed to investigate whether the development of central VF defect mostly affects specific vulnerability zones.

Results  Among the 1103 patients with the most recent VFs, mean (SD) age was 70.4 (14.3) years; mean (SD) 10-2 MD, −21.5 (5.6) dB. Fourteen central VF patterns were determined, including the most common temporal sparing patterns (304 [27.5%]), followed by mostly nasal loss (280 [25.4%]), hemifield loss (169 [15.3%]), central island (120 [10.9%]), total loss (91 [8.3%]), nearly intact field (56 [5.1%]), inferonasal quadrant sparing (42 [3.8%]), and nearly total loss (41 [3.7%]). Location-specific median total deviation analyses partitioned the central VF into a more vulnerable superonasal zone and a less vulnerable inferotemporal zone. At 1-year and 2-year follow-up, new defects mostly occurred in the more vulnerable zone. Initial encroachments on an intact central VF at follow-up were more likely to be from nasal loss (11 [18.4%]; P < .001). One of the nasal loss patterns had a substantial chance at 2-year follow-up (8 [11.0%]; P = .004) to shift to total loss, whereas others did not.

Conclusions and Relevance  In this study, central VF loss in end-stage glaucoma was found to exhibit characteristic patterns that might be associated with different subtypes. Initial central VF loss is likely to be nasal loss, and 1 specific type of nasal loss is likely to develop into total loss.

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