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Editors Selection IGR 14-4
Clinical Examination Methods: 60-4 perimetry catches peripheral defects that central tests miss
Comment by Pradeep Ramulu on:
127808 Analysis of Standard Automated Visual Field Tests in Glaucoma and the Role of Facial Contour, Jamali D S; Garmany A; Kaplan TM et al., Journal of Glaucoma, 2025; 34: 1017-1023
Glaucoma is described as impairing peripheral vision, though the most common visual field testing algorithms focus on relatively central zones (10-30º). Jamali and colleagues tested the more peripheral visual field (out to 60º using the Humphrey 60-4 thresholding algorithm) in patients with OCT-defined glaucoma. The 60-4 visual field testing was much more likely to capture visual defects in eyes with mild disease (sensitivity=87%) as compared to algorithms testing the more central visual field (30-2: 50%; 10-2: 15%). These data support past research suggesting that peripheral visual field testing (beyond the central 30º) can find field defects absent in testing of the more central field.
One problematic artifact in testing of the more peripheral visual field is facial contour: individuals with deep-set eyes or large noses have superior and nasal visual field defects respectively due to their facial anatomy. In a prior publication, the authors developed a CNN algorithm that analyzed facial photographs and, with high accuracy and specificity, predicted visual field defects in normal-sighted individuals on 60-4 testing. Applying this algorithm to a glaucoma group, the authors found that 8% of 60-4 test points were affected by facial contour. In future work, the authors should consider describing the proportion of abnormal peripheral points in glaucoma that are the result of facial contour, as opposed to glaucomatous disease. Additionally, it would be helpful to know if accounting for facial contour can improve the specificity of 60-4 visual field testing in identifying glaucoma.
Further work is also necessary to address other factors challenging the clinical use of more peripheral visual field testing, including test duration, providing adequate refraction without rim artifacts, greater variations in retinal sensitivity in the peripheral field, and peripheral refractive scotomas (particularly in myopic eyes due to a more prolate eye shape).
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