Original articleAssessment of the Reliability of Standard Automated Perimetry in Regions of Glaucomatous Damage

PurposeVisual field testing uses high-contrast stimuli in areas of severe visual field loss. However, retinal ganglion cells saturate with high-contrast stimuli, suggesting that the probability of detecting perimetric stimuli may not increase indefinitely as contrast increases. Driven by this concept, this study examines the lower limit of perimetric sensitivity for reliable testing by standard automated perimetry.DesignEvaluation of a diagnostic test.ParticipantsA total of 34 participants with moderate to severe glaucoma; mean deviation at their last clinic visit averaged −10.90 dB (range, −20.94 to −3.38 dB). A total of 75 of the 136 locations tested had a perimetric sensitivity of ≤19 dB.MethodsFrequency-of-seeing curves were constructed at 4 nonadjacent visual field locations by the Method of Constant Stimuli (MOCS), using 35 stimulus presentations at each of 7 contrasts. Locations were chosen a priori and included at least 2 with glaucomatous damage but a sensitivity of ≥6 dB. Cumulative Gaussian curves were fit to the data, first assuming a 5% false-negative rate and subsequently allowing the asymptotic maximum response probability to be a free parameter.Main Outcome MeasuresThe strength of the relation (R2) between perimetric sensitivity (mean of last 2 clinic visits) and MOCS sensitivity (from the experiment) for all locations with perimetric sensitivity within ±4 dB of each selected value, at 0.5 dB intervals.ResultsBins centered at sensitivities ≥19 dB always had R2 > 0.1. All bins centered at sensitivities ≤15 dB had R2 < 0.1, an indication that sensitivities are unreliable. No consistent conclusions could be drawn between 15 and 19 dB. At 57 of the 81 locations with perimetric sensitivity <19 dB, including 49 of the 63 locations ≤15 dB, the fitted asymptotic maximum response probability was <80%, consistent with the hypothesis of response saturation. At 29 of these locations the asymptotic maximum was <50%, and so contrast sensitivity (50% response rate) is undefined.ConclusionsClinical visual field testing may be unreliable when visual field locations have sensitivity below approximately 15 to 19 dB because of a reduction in the asymptotic maximum response probability. Researchers and clinicians may have difficulty detecting worsening sensitivity in these visual field locations, and this difficulty may occur commonly in patients with glaucoma with moderate to severe glaucomatous visual field loss.