Role of Visual Field Reliability Indices in Ruling Out Glaucoma

IMPORTANCE Standard automated perimetry is the current criterion standard for assessment of visual field (VF) loss in glaucoma. The 3 commonly used reliability indices to judge the quality of standard automated perimetry results are fixation losses (FLs) and false-positive (FP) and false-negative (FN) response rates. However, the influence of reliability indices, when within the manufacturer-recommended limits, on VF classification has been sparsely studied. OBJECTIVE To evaluate the role of VF reliability indices in ruling out glaucoma. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of 291 eyes of 291 participants referred to a tertiary eye care facility by general ophthalmologists. The participants were suspected to have glaucoma based on optic disc appearance, but the eyes were judged to be normal with physiological cupping by glaucoma experts on masked evaluation of optic disc photographs. All participants underwent VF testing with the Swedish interactive threshold algorithm standard 24-2 program. MAIN OUTCOMES AND MEASURES Logistic regression models were used to evaluate the associations between reliability indices and FP classifications on VF testing (glaucoma hemifield test as outside normal limits and pattern standard deviation with P <.05). RESULTS Median FL, FP, and FN response rates were 7%, 1%, and 2%, respectively. Among the 241 participants with reliable VF results (FL < 20% and FP response rate < 15%), the VF classification was normal in 188 (78.0%) and glaucoma (FP) in 53 (22.0%). Probability of FP VF classification was associated with FN response rates (odds ratio [OR], 1.36; 95% CI, 1.25-1.48, P <.001) but did not appear to be associated with FLs (OR, 0.96; 95% CI, 0.90-1.03, P=.30) or FP response rates (OR, 0.96; 95% CI, 0.83-1.12, P=.64). Predicted probability of FP VF classification was 9%(95% CI, 6%-14%), 40% (32%-49%), and 82% (68%-91%) at FN response rates of 0%, 8%, and 16%, respectively. CONCLUSIONS AND RELEVANCE This study suggests that FN response rates have an effect on the ability of automated VF assessments to rule out glaucoma. Since FN response rates are ignored by the manufacturer while flagging a test as unreliable, clinicians and researchers may benefit by realizing that FN response rates can lead to FP VF classification, even when their frequencies are small.