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Original Investigation
April 2, 2020

Pointwise Methods to Measure Long-term Visual Field Progression in Glaucoma

Author Affiliations
  • 1Glaucoma Division, Jules Stein Eye Institute, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
  • 2Department of Ophthalmology, University Vita-Salute, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele, Milan, Italy
  • 3Department of Biostatistics, Jonathan and Karin Fielding School of Public Health, UCLA
JAMA Ophthalmol. 2020;138(5):536-543. doi:10.1001/jamaophthalmol.2020.0647
Key Points

Question  What is the relative performance of 3 pointwise methods to detect visual field progression in primary open angle glaucoma?

Findings  In this cohort study of 567 patients with primary open-angle glaucoma, the glaucoma rate index had the highest detection rate for progression and detected progression earlier than pointwise linear regression or guided progression analysis while maintaining a low rate of false-positive estimates. Agreement among methods was moderate at best and showed differences depending on baseline severity.

Meaning  These results suggest that the glaucoma rate index is a sensitive and specific method that can detect long-term visual field progression in glaucoma earlier than pointwise linear regression or guided progression analysis.

Abstract

Importance  Rates of visual field (VF) progression vary among patients with glaucoma. Knowing the rate of progression of individual patients would allow appropriately aggressive therapy for patients with high rates of visual loss and protect those with low rates from unnecessary therapy.

Objective  To compare 3 pointwise methods of estimating the rate of VF progression in glaucoma.

Design, Setting, and Participants  This retrospective, observational cohort study included 729 eyes of 567 consecutive patients with primary open-angle glaucoma who had at least 6 reliable VFs and at least 3 years of follow-up. One hundred seventy-six patients (257 eyes) were treated at a tertiary glaucoma center; in addition, data were collected from 391 participants (472 eyes) in the Advanced Glaucoma Intervention Study. Data were collected from May 1988 to November 2004 and analyzed from October 2018 to February 2019.

Exposures  Estimates of VF progression were measured with guided progression analysis (GPA), pointwise linear regression (PLR), and the glaucoma rate index (GRI). A subgroup analysis was performed in a subset of patients with likely VF progression and likely VF stability.

Main Outcomes and Measures  Proportion of VF series detected as progressing, estimates of false-positive proportions, time to detect progression, and agreement among measures.

Results  Among the 567 patients included in the analysis, mean (SD) age was 65.6 (9.7) years, 300 (52.9%) were female, and 295 (52.0%) were white. The median baseline mean deviation was −6.7 (interquartile range [IQR], −11.6 to −3.5) dB; the median follow-up time, 8.9 (IQR, 7.3-10.4) years. The proportion of eyes labeled as progressing was 27.7% according to the GPA, 33.5% according to the PLR, and 52.9% according to the GRI; pairwise differences for GRI vs PLR were 20% (95% CI, 17%-23%); for GRI vs GPA, 25% (95% CI, 22%-29%); and for PLR vs GPA, 6% (95% CI, 3%-9%; P < .001 for all comparisons, McNemar test). The shortest median time to progression was with the GRI (8.8 [IQR, 2.4-10.5 years), compared with the GPA and PLR (both >16 years). The hazard ratio of VF progression for GRI vs PLR (reference) was 11.3 (95% CI, 9.2-13.7); for GRI vs GPA (reference), 18.1 (95% CI, 14.5-22.6); and for PLR vs GPA (reference), 1.5 (95% CI, 1.3-1.9; P < .001 for all comparisons, Cox proportional hazards regression). These results held in the subgroup with likely progression; the proportions of progressing eyes were 73.7% (115 of 156) for GPA, 81.4% (127 of 156) for PLR, and 92.9% (145 of 156) for GRI. Pairwise difference for GRI vs PLR was 11.5% (95% CI, 7.4%-17.6%; P < .001, McNemar test); for GRI vs GPA, 19.2% (95% CI, 12.6%-26.4%; P < .001, McNemar test); and for PLR vs GPA, 7.7% (95% CI, 0.3%-15.7%; P = .08, McNemar test).

Conclusions and Relevance  These results suggest GRI can detect long-term VF progression in glaucoma earlier than PLR or GPA. Validation with prospective designs may strengthen the generalizability and value of this method.

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