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Real-World Evidence: Outcomes When Testing Frequency Increases · Glaucoma, Vision & Longevity: Supplements & Science

• 0:00
  SPEAKER_00: Real world evidence.
• 0:01
  SPEAKER_00: Outcomes when visual field testing frequency increases.
• 0:05
  SPEAKER_00: Visual field testing, also called perimetry, measures areas of vision that a person can and cannot see.
• 0:12
  SPEAKER_00: It is especially important in glaucoma because damage to the optic nerve may progress without noticeable symptoms until substantial vision has been lost.
• 0:21
  SPEAKER_00: The practical question is not simply whether more tests produce more data, it is whether more frequent testing leads to earlier detection of true progression, better treatment decisions, preserved vision, and acceptable safety and workload.
• 0:36
  SPEAKER_00: The current evidence suggests that increasing testing frequency usually improves the speed and precision of detecting visual field change.
• 0:44
  SPEAKER_00: However, there is not yet strong proof that more frequent testing alone prevents blindness or improves quality of life.
• 0:52
  SPEAKER_00: Evidence for home visual field testing used alongside clinic care is encouraging, but still based mainly on small, selected studies rather than large comparative outcome trials.
• 1:02
  SPEAKER_00: Key findings at a glance.
• 1:05
  SPEAKER_00: Clinic-based testing every six months detects progression earlier than approximately yearly testing, particularly when overall visual field trends are analyzed.
• 1:14
  SPEAKER_00: In a large United States claims cohort, the median testing frequency was only 0.63 visual field tests per year, and more than three-quarters of patients had fewer than one test per year.
• 1:26
  SPEAKER_00: Home testing can provide weekly or monthly measurements, reduce measurement noise, and sometimes identify a concerning change before the next planned clinic visit.
• 1:36
  SPEAKER_00: Adherence is the main limitation.
• 1:39
  SPEAKER_00: Short studies often report good participation, but longer studies show that testing frequency commonly declines over time.
• 1:47
  SPEAKER_00: More frequent testing also produces more apparent progression signals, some of which later disappear.
• 1:53
  SPEAKER_00: Confirmation rules are therefore essential.
• 1:56
  SPEAKER_00: Direct evidence that increased testing changes long-term visual outcomes remains limited.
• 2:02
  SPEAKER_00: Home testing should generally be treated as an adjunct to clinical examination, not a replacement for eye pressure measurement, optic nerve examination, imaging, and standard clinic-based perimetry.
• 2:14
  SPEAKER_00: What guidelines recommend the European Glaucoma Society notes that there is still no definitive evidence showing which combination of tests or testing frequency produces the best patient outcomes at a sustainable cost.
• 2:27
  SPEAKER_00: Nevertheless, it recommends obtaining enough early visual field measurements to estimate the individual rate of change.
• 2:33
  SPEAKER_00: Newly diagnosed patients are often recommended to have standard automated perimetry approximately three times per year during the first two years, after which the schedule can be tailored to disease severity and observed progression.
• 2:48
  SPEAKER_00: European Glaucoma Society Guidelines.
• 2:50
  SPEAKER_00: The World Glaucoma Association similarly recommends an intensive early series in people at risk of visual disability.
• 2:58
  SPEAKER_00: It suggests that lower risk patients may later be tested about once a year, while higher-risk patients may need testing twice a year or more often if progression is suspected.
• 3:10
  SPEAKER_00: World Glaucoma Association Consensus.
• 3:12
  SPEAKER_00: These recommendations are based largely on the need to establish a reliable baseline and identify fast progression early.
• 3:20
  SPEAKER_00: They should not be interpreted as a requirement for every patient to have the same schedule.
• 3:25
  SPEAKER_00: Testing frequency should reflect existing visual field damage, rate of previous change, age, and expected lifetime risk, whether the patient has only one useful eye, pressure control, optic nerve or retinal nerve fiber layer changes, presence of optic nerve hemorrhage, test reliability, patient ability to attend or complete testing.
• 3:46
  SPEAKER_00: How often are patients actually tested?
• 3:49
  SPEAKER_00: United States nationwide data, a study of 380,029 people with open angle glaucoma found that 8.8% had no visual field tests during the study period, 68.2% received fewer than 0.9 tests per year, only 0.8% received at least 2.1 tests per year.
• 4:07
  SPEAKER_00: The median testing frequency was 0.63 tests per year.
• 4:10
  SPEAKER_00: The authors concluded that more than 75% of the population had fewer than one visual field test per year, which is below the frequency commonly recommended for many patients under active glaucoma monitoring.
• 4:23
  SPEAKER_00: This study described healthcare delivery.
• 4:26
  SPEAKER_00: It did not prove that increasing frequency would prevent vision loss.
• 4:30
  SPEAKER_00: United States Nationwide Glaucoma Cohort, English Hospital Eye Service Data, a large electronic medical record audit evaluated 602,439 visual field records from 73,994 people across five glaucoma clinics in England.
• 4:46
  SPEAKER_00: Among 25,760 patients with repeatable visual field loss, the median interval between visual field tests was 11.2 months.
• 4:55
  SPEAKER_00: Approximately 4.6% of tests were classified as unreliable using the study's reliability measure.
• 5:02
  SPEAKER_00: The median rate of visual field change was approximately minor.21 decibels per year.
• 5:08
  SPEAKER_00: About 24% of patients had advanced field loss at presentation.
• 5:13
  SPEAKER_00: Differences in testing intervals and reliability were observed between clinics.
• 5:18
  SPEAKER_00: This type of registry evidence is valuable because it reflects routine care rather than a highly controlled clinical trial.
• 5:25
  SPEAKER_00: It also demonstrates how electronic records can monitor service quality, identify patients at risk, and measure whether a clinic is delivering testing consistently.
• 5:35
  SPEAKER_00: English glaucoma visual field audit outcomes.
• 5:39
  SPEAKER_00: When clinic-based testing frequency increases, earlier detection of progression.
• 5:44
  SPEAKER_00: One of the clearest real-world analyses came from the Advanced Glaucoma Intervention Study.
• 5:49
  SPEAKER_00: Researchers compared the original series of visual fields with a reduced frequency series created by removing approximately every other follow-up test.
• 5:58
  SPEAKER_00: The higher frequency series had a median of 20 tests compared with 12 tests in the lower frequency series.
• 6:05
  SPEAKER_00: Using a global measure called mean deviation, progression was detected in 43.6% of eyes with the higher frequency data.
• 6:14
  SPEAKER_00: Progression was detected in 34.2% of eyes with the lower frequency data.
• 6:19
  SPEAKER_00: The higher frequency series was about 69% more likely to identify progression using the mean deviation analysis.
• 6:26
  SPEAKER_00: Using a point-by-point analysis, progression was detected in 39.5% of eyes with higher frequency data versus 35.7% with lower frequency data.
• 6:37
  SPEAKER_00: The higher frequency series was still more likely to detect progression, although the difference was smaller.
• 6:43
  SPEAKER_00: Advanced glaucoma intervention study frequency analysis.
• 6:47
  SPEAKER_00: This is important, but it must be interpreted correctly.
• 6:51
  SPEAKER_00: The study showed that more frequent testing detects statistical progression sooner.
• 6:56
  SPEAKER_00: It did not show that the additional tests themselves slowed disease or preserved vision.
• 7:02
  SPEAKER_00: It was also not a randomized trial of two separate monitoring programs.
• 7:06
  SPEAKER_00: The lower frequency series was created by deleting tests from an existing dataset.
• 7:11
  SPEAKER_00: Six-monthly testing may be a practical compromise.
• 7:14
  SPEAKER_00: A longitudinal cohort study used data from 1,072 eyes of 665 patients to model how quickly different rates of glaucoma progression could be detected.
• 7:25
  SPEAKER_00: For eyes losing approximately 2 decibels per year, a progression signal could be detected with 80% statistical power after approximately 3.3 years with yearly testing, 2.4 years with testing twice per year, 2.1 years with testing 3 times per year.
• 7:43
  SPEAKER_00: For slower loss of approximately 0.5 decibels per year, detection took approximately 7.3 years with yearly testing, 5.7 years with twice yearly testing, 5.0 years with testing 3 times per year.
• 7:57
  SPEAKER_00: The improvement from yearly to twice-yearly testing was larger than the improvement from twice-yearly to three times yearly testing.
• 8:05
  SPEAKER_00: The authors concluded that two reliable baseline tests followed by testing approximately every six months with confirmation of suspected progression may offer a practical balance between speed and burden.
• 8:17
  SPEAKER_00: Longitudinal cohort study of visual field testing frequency.
• 8:21
  SPEAKER_00: Personalized schedules may be more efficient than fixed schedules.
• 8:25
  SPEAKER_00: A separate analysis using data from the Advanced Glaucoma Intervention Study and the Collaborative Initial Glaucoma Treatment Study evaluated a personalized testing model.
• 8:37
  SPEAKER_00: The model increased testing when the patient's previous results suggested a higher likelihood of progression and reduced testing when the disease appeared stable.
• 8:46
  SPEAKER_00: Compared with a fixed yearly schedule, the model detected progression 57% sooner, improved progression detection efficiency by 29%.
• 8:56
  SPEAKER_00: Did not require more visual field tests overall.
• 9:00
  SPEAKER_00: This was a model based on previous clinical trial data rather than a prospective implementation study.
• 9:05
  SPEAKER_00: It supports a risk-based approach rather than testing every patient at the same frequency.
• 9:10
  SPEAKER_00: Personalized glaucoma monitoring schedule study.
• 9:14
  SPEAKER_00: Frontloading tests may increase information without adding visits.
• 9:18
  SPEAKER_00: An emerging clinic-based strategy is to perform two visual field tests per eye during the same visit and use their average.
• 9:25
  SPEAKER_00: A 2025 perspective study found that this front-loaded approach reduced variability in global and point-by-point measurements compared with using one test per visit.
• 9:36
  SPEAKER_00: The average rate of progression was similar, but the estimates were more precise.
• 9:41
  SPEAKER_00: Frontloaded visual field testing study.
• 9:44
  SPEAKER_00: This may be useful for patients who cannot perform home testing or who have difficulty attending additional appointments.
• 9:50
  SPEAKER_00: Do more tests lead to more treatment changes?
• 9:54
  SPEAKER_00: The clinical pathway.
• 9:56
  SPEAKER_00: A confirmed visual field decline may lead an eye specialist to lower the target eye pressure, add or change pressure-lowering medicines, recommend laser treatment, consider glaucoma surgery, investigate treatment adherence, shorten the follow-up interval, look for other explanations such as cataract, retinal disease, neurological disease, or poor test reliability.
• 10:19
  SPEAKER_00: However, treatment decisions are rarely based on one visual field test.
• 10:23
  SPEAKER_00: Clinicians usually consider the visual field together with eye pressure, optic nerve appearance, optical coherence tomography imaging, medication use side effects, and the patient's life expectancy.
• 10:35
  SPEAKER_00: Direct evidence remains limited.
• 10:37
  SPEAKER_00: Most studies of increased testing measure earlier detection of statistical progression, not whether treatment was changed or whether vision was ultimately preserved.
• 10:47
  SPEAKER_00: The United Kingdom In-Home Tracking of Glaucoma, reliability, acceptability, and cost feasibility study is one of the few studies reporting treatment changes in a home monitoring program.
• 10:58
  SPEAKER_00: It enrolled 42 people who used a home eye pressure device and a tablet-based visual function application weekly for 12 weeks.
• 11:07
  SPEAKER_00: At the three-month follow-up, two of 42 participants had a clinician-initiated change in glaucoma treatment.
• 11:14
  SPEAKER_00: Three participants withdrew.
• 11:16
  SPEAKER_00: Two withdrawals were related to technology difficulties, and one was related to an unrelated health issue.
• 11:23
  SPEAKER_00: 55% met the study's adherence threshold for both devices.
• 11:27
  SPEAKER_00: 95% completed the three-month follow-up visit.
• 11:31
  SPEAKER_00: This was a short feasibility study and was not designed to determine whether home visual field testing improved long-term outcomes.
• 11:38
  SPEAKER_00: The treatment changes cannot be attributed to the visual field component alone because the program also included home eye pressure monitoring.
• 11:47
  SPEAKER_00: United Kingdom In-Home Monitoring Feasibility Study.
• 11:51
  SPEAKER_00: Detailed study report.
• 11:53
  SPEAKER_00: The most defensible conclusion.
• 11:55
  SPEAKER_00: Increasing testing frequency appears capable of creating earlier opportunities to review and modify treatment.
• 12:01
  SPEAKER_00: But the current evidence does not establish that more frequent visual field testing by itself reduces future visual field loss, blindness, or the need for surgery.
• 12:11
  SPEAKER_00: The likely clinical benefit is indirect.
• 12:14
  SPEAKER_00: More frequent testing may provide earlier warning, which may allow earlier treatment adjustment, but the warning only helps if it is accurate, reviewed promptly, confirmed appropriately, and followed by effective treatment.
• 12:27
  SPEAKER_00: What home visual field testing adds?
• 12:30
  SPEAKER_00: Home testing can be used in two ways.
• 12:33
  SPEAKER_00: Adjunctively, home measurements are collected between clinic visits while routine clinic examination continues.
• 12:40
  SPEAKER_00: As a partial replacement for selected visits, some monitoring may occur remotely with in-person assessment reserved for scheduled reviews or concerning results.
• 12:50
  SPEAKER_00: The evidence is much stronger for the first approach.
• 12:53
  SPEAKER_00: Short-term adherence can be good.
• 12:55
  SPEAKER_00: In a large single-center study of weekly tablet-based testing, 101 participants and 186 eyes were recruited.
• 13:02
  SPEAKER_00: 88% completed at least one home examination.
• 13:06
  SPEAKER_00: 69% completed all six planned home examinations.
• 13:10
  SPEAKER_00: The median interval between tests was approximately seven days.
• 13:14
  SPEAKER_00: Home results showed strong agreement with clinic measurements, with a correlation of approximately 0.85.
• 13:20
  SPEAKER_00: The most common barriers were technology problems, lack of motivation, and competing demands.
• 13:27
  SPEAKER_00: Weekly Home Monitoring Cohort, a smaller study using the eye catcher tablet test, asked 20 adults with glaucoma to perform monthly home testing for six months.
• 13:37
  SPEAKER_00: The study reported approximately 98% adherence to planned tests.
• 13:42
  SPEAKER_00: Strong agreement between home and clinic measurements.
• 13:45
  SPEAKER_00: Reduced measurement error in 97% of eyes when home results were added to two clinic tests.
• 13:51
  SPEAKER_00: More than half reduction in mean absolute measurement error in 90% of eyes.
• 13:56
  SPEAKER_00: A median test duration of approximately 4.5 minutes.
• 14:00
  SPEAKER_00: These results are encouraging, but the participants were volunteers who were able to use the technology and complete the study.
• 14:07
  SPEAKER_00: Eye catcher home visual field study.
• 14:10
  SPEAKER_00: Frequent testing may reduce measurement noise.
• 14:13
  SPEAKER_00: Visual field testing is affected by fatigue, attention, learning, dry eye symptoms, anxiety, and day-to-day variation.
• 14:21
  SPEAKER_00: A single abnormal test may therefore be difficult to interpret.
• 14:24
  SPEAKER_00: Repeated home measurements can help distinguish a persistent trend from an isolated poor result.
• 14:30
  SPEAKER_00: In the two-year Toronto Portable Perimeter Study, 25 patients were enrolled, but only 18 or 72% completed at least one unsupervised home test.
• 14:40
  SPEAKER_00: Those completing tests averaged 1.6 tests per month.
• 14:44
  SPEAKER_00: Home and clinic results were strongly correlated with correlations greater than 0.90.
• 14:50
  SPEAKER_00: Home testing reduced intertest variability and improved the precision of estimated progression rates.
• 14:56
  SPEAKER_00: Compliance declined from 83% during the first two months to 11% during the final two months.
• 15:03
  SPEAKER_00: This illustrates the central implementation challenge.
• 15:06
  SPEAKER_00: Home testing can produce useful data, but long-term adherence cannot be assumed from early participation.
• 15:13
  SPEAKER_00: Two-year virtual reality portable perimetry study.
• 15:17
  SPEAKER_00: Home testing may provide earlier alerts.
• 15:19
  SPEAKER_00: A 12-month tablet-based telemedicine study reported approximately 75% compliance with weekly testing and good agreement with clinic testing.
• 15:28
  SPEAKER_00: In two participants, the home program identified a change approximately 10 weeks before the next planned clinic visit.
• 15:36
  SPEAKER_00: This is an important example of potential lead time, but it does not prove that earlier detection prevented additional vision loss.
• 15:43
  SPEAKER_00: The study population was small and included people with stable treated glaucoma.
• 15:48
  SPEAKER_00: 12-month visual field telemedicine study.
• 15:52
  SPEAKER_00: Home testing is not yet a fully validated replacement.
• 15:56
  SPEAKER_00: A systematic review identified 18 studies of home-based perimeters, including tablet, web-based, and head-mounted systems.
• 16:04
  SPEAKER_00: Most studies were performed in clinics or laboratories rather than in ordinary home settings.
• 16:09
  SPEAKER_00: The review found wide ranges in diagnostic sensitivity and specificity, and all studies reporting diagnostic accuracy had a high risk of bias in at least one area.
• 16:20
  SPEAKER_00: This means that a home device may agree well with clinic testing in selected users while still having uncertain performance in people with advanced glaucoma, people with poor vision or poor fixation, people with cognitive or motor limitations, people with limited digital access, people who are not comfortable using technology, people with coexisting retinal or neurological disease, systematic review of home-based perimetry, clinic-only versus home adjunctive monitoring.
• 16:49
  SPEAKER_00: The available studies do not provide a large, randomized, head-to-head comparison of a clinic-only schedule with a home adjunctive schedule.
• 16:57
  SPEAKER_00: Nevertheless, the practical differences are clear.
• 17:01
  SPEAKER_00: For the full table, please open this article on VisualFieldTest.com.
• 17:06
  SPEAKER_00: The most reasonable current model is therefore hybrid care.
• 17:10
  SPEAKER_00: Continue scheduled clinical assessment while adding home testing for patients in whom more frequent information is likely to change management.
• 17:18
  SPEAKER_00: Safety outcomes and unintended consequences.
• 17:21
  SPEAKER_00: Apparent progression can be a false alarm.
• 17:24
  SPEAKER_00: More testing increases the chance of detecting a real change, but it also increases the number of opportunities for random variation to look statistically significant.
• 17:34
  SPEAKER_00: A 2026 study of 2,133 eyes with 12 consecutive visual field tests found that 21.4% had at least one apparent progression event that later reverted when using a conventional probability threshold.
• 17:48
  SPEAKER_00: The median duration of the apparent event was approximately two visits.
• 17:52
  SPEAKER_00: The proportion of apparent false progression fell to 13.7%, 9.9%, and 7.7% when stricter probability thresholds were used.
• 18:03
  SPEAKER_00: The study defined a false positive progression event as a negative trend that later lost statistical significance.
• 18:10
  SPEAKER_00: Such a reversion may represent measurement variation, learning, cataract-related effects, treatment effects, or a temporarily poor test rather than true glaucoma worsening.
• 18:20
  SPEAKER_00: 2026 Visual Field Progression Reliability Study.
• 18:24
  SPEAKER_00: This finding supports several safety rules.
• 18:26
  SPEAKER_00: Do not change treatment based on one isolated home test.
• 18:30
  SPEAKER_00: Require confirmation when the result is clinically plausible but unexpected.
• 18:35
  SPEAKER_00: Review the raw test, fixation behavior, false positive responses, and test duration.
• 18:40
  SPEAKER_00: Compare the result with optic nerve imaging and eye pressure.
• 18:44
  SPEAKER_00: Use stricter alert thresholds for automated systems.
• 18:48
  SPEAKER_00: Record whether a suspected progression signal was later confirmed or rejected.
• 18:52
  SPEAKER_00: More testing may produce more apparent improvement.
• 18:56
  SPEAKER_00: Increased testing can also identify apparent improvement.
• 18:59
  SPEAKER_00: The advanced glaucoma intervention study frequency analysis found that point-by-point trend analysis detected more eyes with improvement in the higher frequency data set.
• 19:09
  SPEAKER_00: This does not necessarily mean glaucoma damage reversed.
• 19:13
  SPEAKER_00: Visual fields can improve because of learning, better attention, treatment of cataract, improved dry eye symptoms, or random variation.
• 19:22
  SPEAKER_00: A program should therefore track both worsening signals and improvement reversions.
• 19:27
  SPEAKER_00: Transient eye pressure changes after clinic testing.
• 19:30
  SPEAKER_00: A retrospective study of 109 eyes found that eye pressure measured within 30 minutes after automated visual field testing was approximately 1.1 mm of mercury higher than measurements at comparison visits without visual field testing.
• 19:47
  SPEAKER_00: The increase was small and transient, and the study did not show that it caused glaucoma damage.
• 19:53
  SPEAKER_00: This is not a reason to avoid necessary testing, but it is a reminder that eye pressure readings taken immediately after a demanding test should be interpreted in context.
• 20:04
  SPEAKER_00: Study of eye pressure after automated visual field testing.
• 20:07
  SPEAKER_00: Home technology can create safety risks.
• 20:10
  SPEAKER_00: Published home monitoring studies have not established a clear signal of serious eye injury from home visual field testing.
• 20:18
  SPEAKER_00: However, they have documented or raised concerns about technology failure, incorrect setup or positioning, incomplete data transmission, missed alerts, patient anxiety after seeing an abnormal result, false reassurance after an apparently stable result, data privacy and cybersecurity, delayed clinician review, unequal access to devices, broadband, or technical support.
• 20:42
  SPEAKER_00: The United Kingdom In-Home Monitoring Feasibility work found that many participants needed support and that technology difficulties were an important reason for withdrawal or non-adherence.
• 20:53
  SPEAKER_00: Clinicians also expressed concern that replacing routine clinical care too aggressively could create patient safety risks.
• 21:01
  SPEAKER_00: United Kingdom In-Home Monitoring Feasibility Study.
• 21:04
  SPEAKER_00: Important confounders in real-world comparisons.
• 21:08
  SPEAKER_00: A simple comparison between patients who test frequently and those who test infrequently can be misleading.
• 21:13
  SPEAKER_00: Selection bias.
• 21:15
  SPEAKER_00: Home monitoring studies generally enroll people who have reliable prior clinic visual fields, have sufficient visual acuity, can understand instructions, are willing to use technology, have access to a suitable device or internet connection, are motivated to participate.
• 21:33
  SPEAKER_00: The weekly home monitoring cohort, for example, enrolled people with stable glaucoma or ocular hypertension and required adequate vision and English language understanding.
• 21:42
  SPEAKER_00: The two-year portable perimetry study also recruited patients with stable and reliable clinic visual fields.
• 21:49
  SPEAKER_00: These participants may be more capable and engaged than the broader glaucoma population.
• 21:54
  SPEAKER_00: Weekly home monitoring cohort.
• 21:56
  SPEAKER_00: Two-year portable perimetry study.
• 21:58
  SPEAKER_00: Adherence bias.
• 22:00
  SPEAKER_00: People who complete home tests may also be more likely to use eyedrops consistently, attend clinic visits, respond to reminders, report symptoms, follow treatment instructions.
• 22:12
  SPEAKER_00: If these patients have better outcomes, it may be difficult to determine whether the improvement came from more visual field data, better overall engagement, or both.
• 22:21
  SPEAKER_00: Adherence should therefore be analyzed as a changing exposure over time, not simply as used home testing or did not use home testing.
• 22:29
  SPEAKER_00: Confounding by indication.
• 22:31
  SPEAKER_00: Patients with severe disease, rapid previous progression, optic nerve hemorrhage, or poor pressure control are more likely to receive frequent testing.
• 22:41
  SPEAKER_00: They may continue to lose vision despite closer monitoring.
• 22:44
  SPEAKER_00: This can make frequent testing appear associated with worse outcomes even when it was appropriately targeted to higher risk patients.
• 22:52
  SPEAKER_00: Learning effects and regression to the mean, early visual fields often improve as patients learn the test.
• 22:59
  SPEAKER_00: A poor first test may be followed by a better result simply because the patient becomes more familiar with the task.
• 23:06
  SPEAKER_00: Conversely, an unusually good test may be followed by a worse test through ordinary variation.
• 23:12
  SPEAKER_00: Programs should establish a baseline using repeated reliable tests and avoid treating the first abnormal result as definitive.
• 23:21
  SPEAKER_00: Device and strategy differences.
• 23:23
  SPEAKER_00: A tablet or head-mounted perimeter may not measure exactly the same thing as a clinic perimeter.
• 23:29
  SPEAKER_00: Differences may arise from stimulus size and brightness, test pattern, screen calibration, viewing distance, eye tracking, lighting, head position, software algorithms, patient instructions.
• 23:44
  SPEAKER_00: Home testing should therefore be linked to clinic testing through bridge assessments, where both methods are performed close together before the home data are used for trend decisions.
• 23:53
  SPEAKER_00: Treatment changes during follow-up.
• 23:55
  SPEAKER_00: If treatment changes after progression is detected, later stability may reflect effective treatment rather than a naturally stable disease course.
• 24:04
  SPEAKER_00: Conversely, an apparent deterioration may occur before a treatment change has had time to work.
• 24:10
  SPEAKER_00: Analyses should record treatment changes as time-dependent events rather than treating treatment as a fixed baseline characteristic.
• 24:17
  SPEAKER_00: Missing data are usually not random they.
• 24:20
  SPEAKER_00: Patients may stop testing because they become ill, lose interest, develop worse vision, experience technology problems, or become anxious.
• 24:29
  SPEAKER_00: These reasons are clinically meaningful and may be related to outcome.
• 24:33
  SPEAKER_00: A program should record why tests were missed, not just count the missing tests.
• 24:38
  SPEAKER_00: Pragmatic metrics for ongoing program evaluation.
• 24:42
  SPEAKER_00: A useful evaluation program should measure more than the number of tests completed.
• 24:46
  SPEAKER_00: The most important question is whether the additional information is reliable, acted upon, equitable, and clinically useful.
• 24:54
  SPEAKER_00: Reach and representativeness.
• 24:56
  SPEAKER_00: Track.
• 24:57
  SPEAKER_00: Percentage of eligible patients offered home testing.
• 25:00
  SPEAKER_00: Percentage accepting the program.
• 25:02
  SPEAKER_00: Percentage completing onboarding.
• 25:04
  SPEAKER_00: Age, disease severity, language, race and ethnicity, disability, geographic location, and socioeconomic characteristics.
• 25:12
  SPEAKER_00: Percentage unable to participate because of device, internet, language, vision, or motor barriers.
• 25:18
  SPEAKER_00: This identifies whether the program reaches only highly motivated technology users.
• 25:23
  SPEAKER_00: Adherence and persistence.
• 25:24
  SPEAKER_00: Track.
• 25:25
  SPEAKER_00: Tests completed divided by tests scheduled.
• 25:28
  SPEAKER_00: Percentage completed within the planned time window.
• 25:31
  SPEAKER_00: Median interval between tests.
• 25:33
  SPEAKER_00: Percentage completing at least one test per month.
• 25:36
  SPEAKER_00: Adherence during months 1 to 3, 4-6, 7-12, and beyond one year.
• 25:41
  SPEAKER_00: Time to permanent discontinuation.
• 25:44
  SPEAKER_00: Reasons for missed or stop tests.
• 25:46
  SPEAKER_00: Reminder contacts and technical support contacts.
• 25:49
  SPEAKER_00: A single overall adherence percentage can hide a major decline over time, as seen in the two-year portable perimetry study.
• 25:56
  SPEAKER_00: Two-year portable perimetry study.
• 25:58
  SPEAKER_00: Data quality track.
• 26:00
  SPEAKER_00: Percentage of tests meeting reliability criteria, false positive response rate, false negative response rate, fixation losses, test duration, device or software failures, percentage requiring repeat testing, agreement with the patient's next clinic-based standard automated perimetry result, mean absolute difference between home and clinic measurements, change in measurement variability after adding home tests.
• 26:22
  SPEAKER_00: The English Visual Field Audit demonstrates that reliability and testing interval can be measured from electronic records at the clinic level.
• 26:30
  SPEAKER_00: English glaucoma visual field audit alert performance.
• 26:33
  SPEAKER_00: For every home alert, record, date of the first concerning result, date of clinician review, whether the result was confirmed, time from the alert to confirmation, time from confirmation to treatment decision, percentage of alerts that later reverted, percentage of alerts confirmed by clinic testing or another clinical measure.
• 26:54
  SPEAKER_00: Number of missed or delayed alerts.
• 26:56
  SPEAKER_00: Number of alerts that resulted in an unplanned visit.
• 27:00
  SPEAKER_00: A key metric should be the confirmed alert rate rather than the raw number of alerts.
• 27:05
  SPEAKER_00: Treatment actions.
• 27:06
  SPEAKER_00: Track treatment changes per 100 patient years, including new pressure lowering medicine, additional medicine, medication switch, laser treatment, glaucoma surgery, lowered target pressure, treatment de-escalation, unchanged treatment after review, treatment changes made because of confirmed functional progression, treatment changes made for other reasons, such as high eye pressure or medication intolerance.
• 27:32
  SPEAKER_00: Treatment changes should be linked to the evidence that triggered them.
• 27:36
  SPEAKER_00: This avoids incorrectly attributing every change to the home visual field program.
• 27:41
  SPEAKER_00: Visual and patient outcomes.
• 27:43
  SPEAKER_00: The most important long-term outcomes include rate of change in mean deviation, rate of central visual field change, binocular visual field loss, vision-related quality of life, driving or mobility difficulty, loss of sight year estimates, unilateral and bilateral severe visual impairment, need for glaucoma surgery, emergency or unplanned glaucoma visits.
• 28:07
  SPEAKER_00: These outcomes should be measured over several years.
• 28:10
  SPEAKER_00: Earlier detection is useful, but it is only a surrogate outcome unless it leads to better preservation of vision.
• 28:16
  SPEAKER_00: Safety events track serious eye or health events, device-related eye discomfort or injury, anxiety requiring additional support, privacy or data security incidents, false progressional urts, unnecessary treatment changes, delayed treatment because an alert was missed, false reassurance associated with later confirmed progression, transient eye pressure concerns after clinic testing, patient complaints and withdrawal due to burden.
• 28:41
  SPEAKER_00: Safety rates should be reported per 100 patient years when possible so that programs of different sizes and durations can be compared.
• 28:48
  SPEAKER_00: Patient burden and acceptability.
• 28:50
  SPEAKER_00: Measure time spent per test, travel time avoided, out-of-pocket cost, number of support contacts, patient preference for home versus clinic testing, anxiety or reassurance, confidence in the test, willingness to continue, whether the patient feels responsible for interpreting results.
• 29:08
  SPEAKER_00: Home monitoring should not transfer clinical responsibility to the patient.
• 29:12
  SPEAKER_00: Patients should understand that an abnormal home result requires clinician review and that a normal result does not replace routine eye care.
• 29:21
  SPEAKER_00: Clinic workload and cost.
• 29:23
  SPEAKER_00: Track clinici per patient per month, number of alerts per clinician, percentage of alerts requiring a clinic appointment, technical support time, clinic visits avoided, additional clinic visits created by false alarms, cost per confirmed progression, cost per treatment change, cost per quality adjusted life year if a formal economic evaluation is possible.
• 29:47
  SPEAKER_00: A program that produces large amounts of data but overwhelms clinicians may not be sustainable.
• 29:52
  SPEAKER_00: How to evaluate a program fairly.
• 29:55
  SPEAKER_00: A practical evaluation should use a prospective design whenever possible.
• 29:59
  SPEAKER_00: Suitable options include step-twedge implementation.
• 30:04
  SPEAKER_00: Different clinics or patient groups begin home monitoring at different times.
• 30:08
  SPEAKER_00: Each clinic contributes data before and after implementation, allowing the program to be introduced gradually while preserving a comparison period.
• 30:16
  SPEAKER_00: Matched clinic-only comparison.
• 30:19
  SPEAKER_00: Compare home adjunctive patients with similar clinic-only patients matched for age, baseline visual field severity, previous rate of progression, eye pressure, treatment intensity, reliability of prior testing, follow-up duration, socioeconomic and technology access factors.
• 30:36
  SPEAKER_00: Target trial emulation.
• 30:38
  SPEAKER_00: If randomization is not practical, registry data can be analyzed as if patients had been assigned to a home adjunctive or clinic-only strategy.
• 30:46
  SPEAKER_00: The analysis should specify eligibility, treatment strategy, follow-up period, outcomes, and handling of treatment changes before examining results.
• 30:55
  SPEAKER_00: Use both intention to monitor and adherence-based analyses.
• 31:00
  SPEAKER_00: Two results should be reported.
• 31:02
  SPEAKER_00: Intention to monitor, outcomes based on the strategy offered to the patient, regardless of adherence.
• 31:08
  SPEAKER_00: Per protocol, outcomes among patients who completed a pre-specified proportion of scheduled tests.
• 31:13
  SPEAKER_00: Reporting only adherent patients can exaggerate benefit because adherent patients may differ systematically from non-adherent patients.
• 31:23
  SPEAKER_00: A pragmatic care model based on current evidence, a reasonable program would include the following safeguards.
• 31:30
  SPEAKER_00: Continue routine in-person glaucoma assessment.
• 31:33
  SPEAKER_00: Use home testing as an adjunct for patients at higher risk or those who cannot attend frequent visits.
• 31:39
  SPEAKER_00: Perform a clinic-based baseline and at least one close comparison test before relying on home trends.
• 31:45
  SPEAKER_00: Use the same or closely comparable visual field pattern over time.
• 31:50
  SPEAKER_00: Require confirmation of a concerning result before changing treatment unless the clinical picture is clearly urgent.
• 31:56
  SPEAKER_00: Combine visual field results with eye pressure, optic nerve examination, imaging, and medication history.
• 32:03
  SPEAKER_00: Use automated alerts to prioritize review, not to prescribe treatment automatically.
• 32:08
  SPEAKER_00: Provide reminders, technical support, alternate testing arrangements, and language access services.
• 32:14
  SPEAKER_00: Review adherence and data quality continuously.
• 32:17
  SPEAKER_00: Report equity, safety, workload, and long-term visual outcomes, not only test completion.
• 32:23
  SPEAKER_00: Conclusion.
• 32:24
  SPEAKER_00: Real-world evidence consistently shows that increasing visual field testing frequency improves the detection and estimation of glaucoma progression.
• 32:33
  SPEAKER_00: Clinic-based testing every six months generally provides earlier information than approximately yearly testing, while home testing can increase the number of measurements without requiring every test to occur during an office visit.
• 32:47
  SPEAKER_00: Home visual field monitoring is most promising when used between clinic visits, particularly for patients at meaningful risk of progression, patients with limited access to frequent appointments, and patients who can reliably use the technology.
• 33:02
  SPEAKER_00: Early studies show strong agreement with clinic testing and improved measurement precision.
• 33:08
  SPEAKER_00: However, adherence often declines over time, and the available studies are too small and selective to prove that home monitoring preserves vision or reduces blindness.
• 33:19
  SPEAKER_00: The central implementation challenge is balancing signal against noise.
• 33:23
  SPEAKER_00: More data can reveal true deterioration earlier, but it can also create temporary apparent progression, unnecessary anxiety, avoidable visits, or inappropriate treatment changes.
• 33:35
  SPEAKER_00: The safest approach is a hybrid program with confirmation rules, clinician oversight, transparent metrics, and long term evaluation of visual function and quality of life.
• 33:45
  SPEAKER_00: All links to sources are available in the text version of this article.
• 33:50
  SPEAKER_00: You can find the full article at VisualFieldTest.com.
• 33:53
  SPEAKER_00: Thanks for listening.
• 33:54
  SPEAKER_00: To check your visual field, click the link at the bottom of this article or visit visualfieldtest.com.