Performance of the 10-2 and 24-2 Visual Field Tests for Detecting Central Visual Field Abnormalities in Glaucoma ZHICHAO WU, FELIPE A. MEDEIROS, ROBERT N. WEINREB, AND LINDA M. ZANGWILL PURPOSE: To compare the performance of the pattern Ophthalmol 2018;196:10–17. Ó 2018 Elsevier Inc. standard deviation (PSD) values derived from the central All rights reserved.) 12 locations of the 24-2 visual field test (C24-2) to the entire 10-2 test for detecting central visual field abnor- malities in eyes with, suspected of having, or at risk of ISUAL FIELD TESTING REMAINS ONE OF THE MOST having glaucoma. important tools in glaucoma clinical management, DESIGN: Cross-sectional case-control study. V allowing the nature of visual function loss to be METHODS: Eyes with, suspected of having, or at risk of characterized and monitored over time. Its results are having glaucoma, based on masked grading of optic disc crucial for understanding both the current state and future stereophotographs and/or ocular hypertension (intraoc- risk of functional disability for individuals affected by this 1,2 ular pressure ‡ 22 mm Hg) were included as cases (n [ disease. An accumulating body of evidence has 523). Eyes from healthy participants were included as recently revealed that glaucomatous damage can often controls (n [ 107) to allow the 2 tests to be compared affect the macula region, even in the early stages of this 3 at matched specificities. The sensitivity to detect cases disease. This region is particularly important for daily at 95% specificity using PSD values derived from the functioning, and previous studies have reported that entire 10-2 test and C24-2 were compared. central visual function loss is strongly associated with 4–6 RESULTS: The sensitivity of the 10-2 and C24-2 PSD self-reported quality of life. As such, evidence-based values was not significantly different between the 10-2 guidance on how to optimally detect and monitor central and C24-2 at matched specificities (35.9% and 35.4% visual function loss would be tremendously beneficial for respectively; P [ .900). There was also a substantial clinicians, but this remains to be established. agreement between the cases detected by both methods Recent studies have evaluated whether performing dedi- (kappa [ 0.80 ± 0.04), and a very strong cated central visual field tests (such as with the 10-2 strat- association between the PSD values from the 2 egy on the Humphrey Field Analyzer [HFA]; Carl Zeiss 6–10 methods (R2 [ 0.91). Meditec, Dublin, California, USA) or modifying the CONCLUSIONS: 10-2 and 24-2 tests identified a conventional stimulus patterns (such as the 24-2 strategy 11,12 similar number of eyes with, suspected of having, or on the HFA) would improve the detection of central at risk of having glaucoma as having central visual field visual dysfunction. Some studies have recommended that abnormalities using PSD values. These findings do not 10-2 visual field tests should be performed in the clinical mean that 10-2 tests are not useful, but highlight management of patients with glaucoma, on the basis that: the need for further studies to determine the potential (1) summary metrics on the 24-2 visual field test often advantages of 10-2 tests through equivalent missed topographically consistent abnormalities detected comparisons against 24-2 tests to ensure appropriate on the 10-2 test and optical coherence tomography 7 recommendations are made about its incorporation (OCT) macular scans, (2) glaucoma eyes with normal 8 into the glaucoma standard of care. (Am J 24-2 results often had abnormal 10-2 results, and (3) the 10-2 binocular mean sensitivity was more strongly associated with vision-related quality of life than the 6 Supplemental Material available at AJO.com. same measure from the 24-2 test. Accepted for publication Aug 3, 2018. However, all of these studies have compared the re- From the Hamilton Glaucoma Center, Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA (Z.W., sults of the entire 24-2 test with those from the 10-2 R.N.W., L.M.Z.); Centre for Eye Research Australia, Royal Victorian test, rather than evaluating the topographically equiva- Eye and Ear Hospital, East Melbourne, Victoria, Australia (Z.W.); lent central locations of the 24-2 test. Instead, 2 previous Ophthalmology, Department of Surgery, The University of Melbourne, 9,10 Melbourne, Victoria, Australia (Z.W.); and Duke Eye Center and studies demonstrated that abnormalities in these Department of Ophthalmology, Duke University School of Medicine, central locations of the 24-2 test were highly Durham, North Carolina, USA (F.A.M.). associated with those from the 10-2 test. Thus, it Inquiries to Zhichao Wu, Centre for Eye Research Australia, Level 7, 32 Gisborne St, East Melbourne, VIC 3002, Australia; e-mail: wu.z@unimelb. remains to be determined whether, and the extent to edu.au which, central visual field abnormalities can be 10 © 2018 ELSEVIER INC.ALL RIGHTS RESERVED. 0002-9394/$36.00 https://doi.org/10.1016/j.ajo.2018.08.010 detected with the 24-2 central locations when compared to the 10-2 test. To examine this, we used the pattern standard deviation (PSD) measure to compare the 2 tests at topographically matched locations, and at matched specificities. Although PSD values are not used clinically in isolation to detect visual field abnormalities, they have been widely used for defining the presence and identifying the development of visual field abnormalities in research studies.13–16 Thus, this comparison could provide important insights into understanding the interpretation of central visual dysfunction defined by 10-2 vs the central locations of 24-2 test patterns in research studies. This study was therefore undertaken to compare the summary statistics from 10-2 and 24-2 tests at matched specificities and topographic locations for defining central visual field abnormalities for glaucoma research. FIGURE 1. Plot of the 10-2 and 24-2 visual field test locations for a left eye, shown using circular and square markers, respec- tively. The central 12 locations of the 24-2 test are highlighted METHODS using the black square markers. PARTICIPANTS INCLUDED IN THIS STUDY WERE EVALUATED in 2 prospective observational studies of optic nerve struc- ture and visual function longitudinally in glaucoma—the Diagnostic Innovations in Glaucoma Study (DIGS) and participants who had an unremarkable ophthalmologic the African Descent and Glaucoma Evaluation Study examination and intraocular pressures below 22 mm Hg. (ADAGES).15 Institutional review board approvals were In addition, all the eyes included in this study were obtained from each of the sites involved in the studies, required to have a best-corrected visual acuity of 20/40 and the studies were conducted in adherence to the Decla- or better and open angles on gonioscopy, and the partic- ration of Helsinki and to the Health Insurance Portability ipants were required to be older than 18 years of age. and Accountability Act, and all participants provided writ- Participants that had any other ocular or systemic disease ten informed consent. that could affect the optic nerve or the visual field were The details of the testing performed by the participants excluded from this study. Visual fields were not used in in these studies have been described previously.15 In brief, the classification of cases or controls. all participants underwent an annual comprehensive ophthalmologic evaluation that included a medical his- VISUAL FIELD TESTING: All eyes included were required tory review, best-corrected visual acuity measurements, to have a reliable 10-2 and 24-2 visual field test performed slit-lamp biomicroscopy, dilated fundus examination and on the same day, and a visual field test was considered optic disc stereophotography, and intraocular pressure unreliable if there was > 33% fixation losses or > 33% and pachymetry measurements. Participants included in false-negative errors (except when the mean deviation this study also performed visual field testing with the [MD] was < À12 dB), or > 15% false-positive errors. All Swedish Interactive Thresholding Algorithm Standard tests were reviewed for the presence of artifacts, including 24-2 and 10-2 strategy on the HFA II-i (Carl Zeiss inappropriate fixation, fatigue, inattention or learning Meditec, Dublin, California, USA), approximately semi- effects, eyelid or rim artifacts, or any evidence that the annually. results were affected by a condition other than glaucoma As this was a cross-sectional case-control study, eyes (eg, homonymous hemianopia). This quality review was with, suspected of having, or at risk for having glaucoma performed by experienced graders at the University of were included as cases and healthy eyes as controls. The California, San Diego (UCSD) Visual Field Assessment cases included eyes considered to have glaucomatous Center,17 and any test with such artifacts was excluded optic neuropathy based on the masked grading of the from this study. optic nerve appearance on stereophotographs by at least In order to compare the diagnostic performance of the 2 graders, as described in detail previously.15 It also 24-2 and 10-2 test, the central 12 locations of the 24-2 included eyes with ocular hypertension, which was (or C24-2) were evaluated owing to its close spatial corre- defined as having an intraocular pressure of 22 mm Hg spondence with the region sampled by the 10-2 test; the or greater. The control group included eyes from healthy locations sampled by both tests are shown in Figure 1. VOL. 196 10-2 AND 24-2 VISUAL FIELDS IN GLAUCOMA 11 TABLE 1. Characteristics of the Study Eyes and Participants Healthy (N ¼ 107 Eyes) Glaucoma (N ¼ 523 Eyes) Age (y)a 64 6 11 70 6 11 24-2 MD (dB) À0.26 (0.72 to À1.44) À1.76 (À4.98 to 0.09) 24-2 PSD (dB) 1.78 (1.52 to 2.32) 2.33 (1.67 to 6.20) Study parametersb 10-2 MD (dB) 0.17 (À1.17 to 0.83) À1.25 (À4.42 to 0.25) 10-2 PSD (dB) 0.83 (0.69 to 1.10) 1.11 (0.79 to 3.64) C24-2 MD (dB) À0.43 (À1.54 to 0.60) À1.19 (À4.88 to 0.03) C24-2 PSD (dB) 0.86 (0.76 to 1.05) 1.06 (0.81 to 2.93) MD ¼ mean deviation; PSD ¼ pattern standard deviation.