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Editors Selection IGR 19-2

Clinical Examination Methods: Tele-Perimetry: Relaibility and Compliance

Comment by Vincent Michael Patella on:

104766 Test Reliability and Compliance to a Twelve-Month Visual Field Telemedicine Study in Glaucoma Patients, Prea SM; Vingrys AJ; Kong GYX, Journal of clinical medicine, 2022; 11:

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The authors sought to quantify reliability and compliance of glaucoma patients to a weekly home visual field (VF) testing schedule and to determine the concordance of home results with in-clinic outcomes. One eye of 47 stable glaucoma patients having at least two reliable baseline Humphrey 24-2 fields was enrolled. Mean age was 64 years. Subjects were tasked with performing home VF testing weekly for 52 weeks, using the Melbourne Rapid Fields (MRF) perimetry software for the Apple iPad.¹ At baseline, patients were introduced to the MRF and given in-clinic supervised training on how to perform the test. Patients were also examined clinically at baseline, six months after baseline, and upon study completion; during clinical visits, Humphrey 24-2 perimetry and MRF testing were performed.

Perimetric learning effects were found to persist until about ten home examinations had been completed, and 14 subjects who did not progress past the perimetric 'learning phase' were subsequently excluded. An additional 13 subjects were excluded for other deficiencies. After one year, the results were analyzed from the remaining 20 subjects who had completed a minimum of three additional reliable Humphrey fields, one at each clinic visit, and had performed at least ten MRF home examinations. In this analyzed group, compliance to weekly home monitoring was 75% (15 subjects out of 20) in the presence of weekly tekst reminders.

Of the 757 home examinations performed, approximately 65% met the authors' reliability requirements, compared to 85% for clinical test result

Of the 757 home examinations performed, approximately 65% met the authors' reliability requirements, compared to 85% for clinical test results. Two eyes were found to have VF progression during the 12-month study, and both were detected earlier by home testing than via clinical measures. The authors concluded that weekly home testing over 12 months returned good concordance to in-clinic assays. No statistically significant differences in Mean Deviation, Pattern Standard Deviation, test variability or rate of progression were found between Humphrey, clinical testing with MRF, and MRF home testing.

One initial response to these findings might be to question the whole idea of home perimetry. If only 20 out of 74 subjects could clear the seemingly low bar of performing ten home tests and three clinical VFs over the course of a year, is there a future for home-based perimetry?

If only 20 out of 74 subjects could clear the seemingly low bar of performing ten home tests and three clinical VFs over the course of a year, is there a future for home-based perimetry?

However, I believe that these results may be better understood in the context of earlier trials performed by this group.^1-5 Firstly, in a six-month clinical study comparing their MRF results to HFA, the authors found the two devices to have similar repeatability.⁴ Secondly, in a trial similar in design to the present 12-month trial, 101 participants were tasked with performing six unsupervised MRF home examinations in six weeks, and 69% completed all six examinations. The MRF home Mean Deviation (MD) and Humphrey clinical MDs showed an R² of 0.72.⁵ These two trials suggest to me that many but not all patients may be willing and able to produce useful home-based perimetry test results using the MRF device over short periods of time, for example, six weeks.

In the above context, the present paper seems to suggest that we do not yet understand how to successfully organize and execute long term home perimetric testing programs, and that our primary problem with long term home perimetry may be patient adherence. We have long known that poor patient adherence to treatment of chronic diseases is a significant problem.⁶ Why would we think that adherence to a novel program of home VF testing should be less challenging? The authors understand this and have made a number of thoughtful suggestions for improved patient adherence.

This is only the beginning for home perimetry. For instance, only two groups worldwide were cited in a June 2022 review of the home perimetry literature as actually having performed home-based perimetric testing trials evaluating detection and quantification of glaucomatous progression.⁷ The present authors comprise one of those two groups, and we must congratulate and thank them for taking the lead in a difficult and complex new arena. With their help and the help of others, we will figure this out.

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