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Original Investigation
February 2018

Comparison of Quality and Output of Different Optimal Perimetric Testing Approaches in Children With Glaucoma

Author Affiliations
  • 1Life Course Epidemiology and Biostatistics Section, University College London Great Ormond Street Institute of Child Health, London, England
  • 2Ulverscroft Vision Research Group, London, England
  • 3National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
  • 4Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, England
  • 5Glaucoma Service, Moorfields Eye Hospital National Health Service Foundation Trust, London, England
  • 6Clinical Epidemiology, Nutrition and Biostatistics Section, National Health Service Great Ormond Street Institute of Child Health, London, England
JAMA Ophthalmol. 2018;136(2):155-161. doi:10.1001/jamaophthalmol.2017.5898
Key Points

Question  What is the quality and output of different perimetric approaches in children with glaucoma?

Findings  In this cross-sectional study, test quality improved with increasing age for all approaches (65 children aged 5-15 years). Static perimetry appeared to be effective and appropriate in children younger than 10 years and for detecting mild field restriction, and far-peripheral kinetic perimetry was feasible and added value to assessment of older children, especially with severe visual field restriction, highlighting potential use in monitoring disease progression.

Meaning  These data suggest that monitoring visual fields in childhood glaucoma should consider age, disease severity, and different strengths of static vs kinetic tests.


Importance  There is limited evidence to support the development of guidance for visual field testing in children with glaucoma.

Objective  To compare different static and combined static/kinetic perimetry approaches in children with glaucoma.

Design, Setting, and Participants  Cross-sectional, observational study recruiting children prospectively between May 2013 and June 2015 at 2 tertiary specialist pediatric ophthalmology centers in London, England (Moorfields Eye Hospital and Great Ormond Street Hospital). The study included 65 children aged 5 to 15 years with glaucoma (108 affected eyes).

Main Outcomes and Measures  A comparison of test quality and outcomes for static and combined static/kinetic techniques, with respect to ability to quantify glaucomatous loss. Children performed perimetric assessments using Humphrey static (Swedish Interactive Thresholding Algorithm 24-2 FAST) and Octopus combined static tendency-oriented perimetry/kinetic perimetry (isopter V4e, III4e, or I4e) in a single sitting, using standardized clinical protocols, administered by a single examiner. Information was collected about test duration, completion, and quality (using automated reliability indices and our qualitative Examiner-Based Assessment of Reliability score). Perimetry outputs were scored using the Aulhorn and Karmeyer classification. One affected eye in 19 participants was retested with Swedish Interactive Thresholding Algorithm 24-2 FAST and 24-2 standard algorithms.

Results  Sixty-five children (33 girls [50.8%]), with a median age of 12 years (interquartile range, 9-14 years), were tested. Test quality (Examiner-Based Assessment of Reliability score) improved with increasing age for both Humphrey and Octopus strategies and were equivalent in children older than 10 years (McNemar test, χ2 = 0.33; P = .56), but better-quality tests with Humphrey perimetry were achieved in younger children (McNemar test, χ2 = 4.0; P = .05). Octopus and Humphrey static MD values worse than or equal to −6 dB showed disagreement (Bland-Altman, mean difference, −0.70; limit of agreement, −7.74 to 6.35) but were comparable when greater than this threshold (mean difference, −0.03; limit of agreement, −2.33 to 2.27). Visual field classification scores for static perimetry tests showed substantial agreement (linearly weighted κ, 0.79; 95% CI, 0.65-0.93), although 25 of 80 (31%) were graded with a more severe defect for Octopus static perimetry. Of the 7 severe cases of visual field loss (grade 5), 5 had lower kinetic than static classification scores.

Conclusions and Relevance  A simple static perimetry approach potentially yields high-quality results in children younger than 10 years. For children older than 10 years, without penalizing quality, the addition of kinetic perimetry enabled measurement of far-peripheral sensitivity, which is particularly useful in children with severe visual field restriction.