Glaucoma is a leading cause of blindness both in the US and worldwide. The long-term purpose of this project is to improve functional testing in glaucoma. Assessment and follow-up of patients currently relies on automated perimetry to provide functional testing of the visual field. However, the ability to assess progression and/or response to treatment using perimetry is hampered by high variability, especially in areas of moderate or severe glaucomatous damage. Recent findings by our laboratory and others have advanced our understanding of perimetry by challenging key assumptions about the test. This proposal aims to use these advances to explain and reduce the test variability. This will improve the accuracy, efficiency and utility of current functional testing, giving immediate impact in both research and clinical settings, and laying groundwork for the next generation of instruments and algorithms. The first Specific Aim is to produce an accurate and physiologically justified measure of the Effective Dynamic Range (EDR) of perimetry. It is postulated that the very high contrast stimuli used by perimetry in glaucomatous defects saturate the response of the visual system. The resultant nonlinearity in the contrast-response function would cause the detection probability to asymptote below 100%, explaining the high variability in sensitivities in damaged areas. The limit of the EDR will be defined as the contrast beyond which response linearity cannot be assumed. This will be measured by collecting frequency-of-seeing curves in subjects with moderate or advanced glaucoma. The same technique will be used to determine whether the EDR is extended by use of an increased stimulus size. The second Specific Aim is to derive and test a spatial filter to reduce the variability. This will be the first filter to be based both on sensitivities at other locations in the visual field and on the structure of the optic nerve head. The third Specific Aim is to assess the potential utility of using a linear scale for sensitivity, rather than the current logarithmic decibel scale. First, an efficient linear-scaled thresholding algorithm will be derived and tested, to determine whether it will reduce variability both between tests and in the structure-function relation. Second, linear-scaled global indices of the central visual field will be examined, to determine whether they offer improved prognostic value compared with current decibel-scaled indices when assessing progression. The three aims are complementary. It is anticipated that by combining these aims, variability in perimetry will be better understood, and significantly reduced. Such an improvement in a test as commonly performed as perimetry will significantly impact future clinical practice.

Public Health Relevance

This project aims to explain and reduce the variability observed in functional testing of the visual field in patients with glaucoma. This will allow earlier and more accurate assessment of a patient's current status and response to treatment. It will improve the ability to design an appropriate and cost-efficient personalized management strategy to preserve vision, with the aim of maintaining a patient's quality of life.

National Institute of Health (NIH)
National Eye Institute (NEI)
Research Project (R01)
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Study Section
Anterior Eye Disease Study Section (AED)
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Chin, Hemin R
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Emanuel Hospital and Health Center
United States
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Gardiner, Stuart K (2018) Differences in the Relation Between Perimetric Sensitivity and Variability Between Locations Across the Visual Field. Invest Ophthalmol Vis Sci 59:3667-3674
Pathak, Manoj; Demirel, Shaban; Gardiner, Stuart K (2017) Reducing Variability of Perimetric Global Indices from Eyes with Progressive Glaucoma by Censoring Unreliable Sensitivity Data. Transl Vis Sci Technol 6:11
Gardiner, Stuart K; Mansberger, Steven L; Demirel, Shaban (2017) Detection of Functional Change Using Cluster Trend Analysis in Glaucoma. Invest Ophthalmol Vis Sci 58:BIO180-BIO190
Gardiner, Stuart K; Demirel, Shaban (2017) Detecting Change Using Standard Global Perimetric Indices in Glaucoma. Am J Ophthalmol 176:148-156
Gardiner, Stuart K; Mansberger, Steven L (2016) Effect of Restricting Perimetry Testing Algorithms to Reliable Sensitivities on Test-Retest Variability. Invest Ophthalmol Vis Sci 57:5631-5636
Gardiner, Stuart K; Swanson, William H; Demirel, Shaban (2016) The Effect of Limiting the Range of Perimetric Sensitivities on Pointwise Assessment of Visual Field Progression in Glaucoma. Invest Ophthalmol Vis Sci 57:288-94
Gardiner, Stuart K; Fortune, Brad; Demirel, Shaban (2016) Localized Changes in Retinal Nerve Fiber Layer Thickness as a Predictor of Localized Functional Change in Glaucoma. Am J Ophthalmol 170:75-82
Gardiner, Stuart K; Demirel, Shaban; Reynaud, Juan et al. (2016) Changes in Retinal Nerve Fiber Layer Reflectance Intensity as a Predictor of Functional Progression in Glaucoma. Invest Ophthalmol Vis Sci 57:1221-7
Gardiner, Stuart K; Demirel, Shaban; Goren, Deborah et al. (2015) The Effect of Stimulus Size on the Reliable Stimulus Range of Perimetry. Transl Vis Sci Technol 4:10
Pathak, Manoj; Demirel, Shaban; Gardiner, Stuart K (2015) Nonlinear Trend Analysis of Longitudinal Pointwise Visual Field Sensitivity in Suspected and Early Glaucoma. Transl Vis Sci Technol 4:8

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