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. 2024 Feb 14;38(8):1549–1555. doi: 10.1038/s41433-024-02949-x

Visual field progression patterns in the ocular hypertension treatment study correspond to vulnerability regions of the disc

Ari Leshno 1,2, Nikhil Bommakanti 1,3, Carlos Gustavo De Moraes 1,✉, Mae O Gordon 4, Michael A Kass 4, George A Cioffi 1, Jeffrey M Liebmann 1
PMCID: PMC11126578  PMID: 38355667

Abstract

Objectives

To determine the locations on the 24-2 visual field (VF) testing grid that are most likely to progress in patients with ocular hypertension (OHTN). Based on a structural model of superior and inferior areas of relative vulnerability at the optic disc, we hypothesized that the nasal and paracentral regions are more prone to show a reduction in sensitivity.

Methods

Posthoc analysis of data collected in phases 1 and 2 of the Ocular Hypertension Treatment Study (OHTS). A pointwise analysis was applied to determine the progression patterns in the early and delayed treatment groups. Each group’s progression rate and frequency were calculated for each of the 52 locations corresponding to the 24-2 VF strategy, using trend- and event-based analyses, respectively.

Results

For the event-based analysis, the events were most commonly found in the nasal and paracentral regions. The same regions, with some modest variation, were found to have the fastest rates of progression (ROP) measured with trend analysis. A similar pattern of progression was observed in both the early and delayed treatment groups. The difference in event rates and ROP between the early and delayed treatment groups was also greatest in the nasal and paracentral regions.

Conclusions

Development of VF loss in ocular hypertensive eyes appears to be consistent with the vulnerability zones previously described in glaucomatous eyes with established VF loss. Ocular hypotensive treatment likely helps to slow the rate of progression in these regions. This suggests that careful monitoring of these locations may be useful.

Subject terms: Glaucoma, Eye manifestations

Introduction

Structurally, glaucomatous optic neuropathy has a characteristic loss of the retinal ganglion cell layer (GCL) and retinal nerve fibre layer (RNFL) which results in corresponding patterns of visual field (VF) loss. Hood et al. examined the location of local glaucomatous damage around the optic disc among eyes with early glaucoma (i.e., VF 24-2 mean deviation (MD) better than -6dB) and identified areas of relative vulnerability to glaucomatous damage [1]. Consistent with previous histology and optical coherence tomography (OCT) measurements by others [2–6], they found that damage is most likely to occur in the major RNFL bundles within the superior and inferior quadrants, particularly in the temporal half of these quadrants. Based on these findings, Hood et al. [7]. developed a schematic model for early glaucomatous damage, in which these regions were referred to as the superior vulnerability zone (SVZ) and inferior vulnerability zone (IVZ), respectively (Fig. 1a). Although the model has been consistent in multiple studies, to the best of our knowledge, this theoretical pattern of progression has not been validated in eyes that were initially healthy (based on optic-disc and VF examination) at baseline and later developed glaucomatous damage. Furthermore, it is unclear how intraocular pressure (IOP)-lowering treatment affects the rates of change corresponding to these most vulnerable regions.

Fig. 1. The vulnerability zones model.

Fig. 1

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a The original schematic model (right eye vertically inverted for field view orientation) published by Hood et al. [7] showing the location of the superior vulnerability zone (SVZ, orange) and the inferior vulnerability zone (IVZ, green) on the temporal half of the disc. b Schematic model (right eye in field view orientation) highlighting the 24-2 visual field regions of vulnerability based on spatial correspondence to the IVZ and SVZ at the disc. The borders of the superior (red) and inferior (blue) regions supplying input to the temporal half of the disc are superimposed on retinal nerve fibre layer tracings modified from Fig. 3 by Jansonius et al. [8], with permission. The points on each hemifield on the 24-2 that are expected to have the greatest overlap (top quartile) with the corresponding disc vulnerability zone are marked by a yellow circle.

Ocular hypertension (OHTN) is one of the most important risk factors for developing primary open-angle glaucoma (POAG). More importantly, lowering the IOP is currently the only proven treatment method to slow or halt the rate of progression (ROP) in glaucoma. Although patients with OHTN do not have evidence of optic neuropathy nor any detectable perimetric defect using conventional methods (i.e., optic disc examination and standard automated perimetry), they are considered at higher risk for developing glaucoma. The Ocular Hypertension Treatment Study (OHTS) was a landmark clinical trial that helped better describe the natural history of OHTN and conversion to POAG while demonstrating that treatment to lower IOP could reduce the risk for conversion to POAG by 50% [8]. The OHTS data offers a unique opportunity to determine patterns of VF loss for several reasons. First, it is the most extensive randomized-control study to date on OHTN with a very long duration of follow-up. Second, the study employed repeated standard automated perimetry (SAP), considered the reference standard for assessing functional damage in glaucoma. As per the study design, all participants had to have repeated normal VF tests at the beginning of the study (defined as a Glaucoma Hemifield Test [GHT] [9] and Corrected Pattern Standard Deviation [CPSD] within normal limits [10, 11]), thereby allowing for identification of very early VF loss. Lastly, while only one study arm was given IOP-lowering medication during the first phase of the study (OHTS Phase 1), after five years (OHTS Phase 2), both groups were offered treatment, allowing the investigation of the effect of early versus delayed treatment on progressive changes in the VF.

The purpose of this study is to utilize the OHTS dataset (from Phases 1 and 2) to determine the pattern of VF loss by identifying the locations on the 24-2 VF grid that progress most rapidly and frequently and to evaluate the effect of treatment on these regions.

Methods

Subjects

This study included data collected in the first two phases of the OHTS study through December 30, 2008. The design of the OHTS has been described previously (www.clinicaltrials.gov, registration number NCT00000125) [1]. Briefly, the study was conducted in three phases: the first phase (OHTS Phase 1) was a randomized clinical trial conducted from February 28, 1994, to June 2, 2002. Between February 1994 and October 1996, 1636 participants with OHT were randomized to receive either topical ocular hypotensive medication (medication group) or close observation (observation group). The second phase (OHTS Phase 2) was conducted from June 3, 2002, to December 30, 2008. During this phase, both groups received treatment: the original medication group continued to receive treatment (early medication group), and hypotensive treatment was offered to the original observation group (delayed medication group). In the third phase (OHTS Phase 3), treatment was no longer determined by the study protocol and was not included in our analysis.

All participants in the OHTS signed a statement of informed consent approved by the institutional review board of each participating clinic. The study adhered to the tenets of the Declaration of Helsinki and was in compliance with the Health Insurance Portability and Accountability Act.

Visual field data

We included 2,749,398 test points from 58,115 visual fields of 1,188 patients (2,369 eyes) that participated in the OHTS and met the following criteria: 1) a series of at least six reliable visual fields which were performed over at least six years of follow-up and 2) each eye was required to have at least two qualifying visual field tests with normal GHT, normal PSD (P < 5%), and less than 33% fixation losses, false positive results, and false negative (as per the OHTS criteria) [12].

Since the early visual field testing paradigm used the 30-2 pattern and did not use the SITA algorithm, to maintain consistency the 52 locations of the 24-2 grid (54 minus 2 points for the blind spot) were retained from the 30-2 grid. During the commencement of the second phase of the OHTS, the testing algorithm was switched from Full Threshold to SITA-Standard. In order to permit a comparison between the two testing algorithms, and maintain consistency with prior OHTS work [13], a correction factor of +1.0 dB was applied to threshold sensitivities measured using the Full Threshold [14, 15]. The number of VF tests and length of follow-up for the early and delayed medication groups are presented in Fig. 2. The first two baseline tests were used for reference values.

Fig. 2. Overview of the collected visual field data.

Fig. 2

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Number of fields (a) and follow-up duration (b) for the delayed and medication groups.

Schematic model to predict the points most likely to progress on the 24-2

The vulnerability regions described by Hood et al. include the temporal half of the superior and inferior quadrants of the disc (i.e., 45 to 90 degrees and -45 to -90 degrees in Fig. 1a), defined as the SVZ and IVZ, respectively. Although the SVZ and IVZ represent a relatively small (45°) region of the disc, defects in these regions can still vary in location, depth, and width, as well as homogeneity. Thus, the corresponding VF defects seen on a 24-2 VF can show a wide range of patterns [12]. Based on previous work by Janosnious et al. [16]. we identified for each hemifield the points on the 24-2 that are expected to have the greatest overlap (top quartile) with the corresponding disc vulnerability zone. As depicted in Fig. 1b (yellow circles), the points are located in the nasal and paracentral region (notice that the fundus image is vertically inverted for field view). We hypothesize that these locations would show progression more commonly than other VF points.

Identifying Vulnerability Regions on the 24-2 using the OHTS dataset

Data cleaning, analysis, summarization, visualization, and manuscript preparation were performed using the R statistical programming language [17–23]. In order to identify the regions vulnerable to progression on the 24-2 VF, two independent endpoints were devised to define pointwise progressive loss using both event-based and trend-based analysis. In an event-based analysis, each observation is compared to a reference, and a binary event occurrence is determined. Since the commercial pointwise threshold sensitivity cutoffs are not publicly available, we used the OHTS database to determine the threshold sensitivity cutoffs that were defined by the 5% limit of variability using the qualification test and test-retest for each point (Figure S1).

A pointwise event was defined as a single field point having three consecutive threshold sensitivity observations below the respective pointwise cut-off, and the time of the event was defined as the time of the first observation in the triplet (Figure S2). As follows from this definition, one eye was permitted to have multiple pointwise events (e.g., two separate points satisfying the above criteria).

Trend analysis with pointwise linear regression utilizes all eligible data and their relationship to time to determine the rate of change. For every eye, the rate of change in threshold sensitivity was determined at each of the 52 test points by extracting the slope from a linear regression model of threshold (dB) versus time. Figure S3 provides an example of this analysis for one eye. The mean slope (dB/year) was calculated and compared between the two groups for each VF point.

Results

Event-based analysis

In the event-based analysis, at least one pointwise event occurred in 1547 (65.3%) of the 2369 eyes included in the study. The frequency of pointwise events varied across the 52 visual field points from 0.9% to 5.2% in the early medication group (median: 2.1%, IQR: 1.5-3.0%) and from 1.5% to 6.4% in the delayed medication group (median: 3.1%, IQR: 2.4-4.0%). Figure 3 shows the mean percentage of pointwise events within each field point for the delayed and early medication groups. The events were concentrated in the nasal and paracentral regions in both groups.

Fig. 3. Event based analysis.

Fig. 3

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The mean percentage of pointwise events in the delayed (A) and early (B) medication groups: The frequency of pointwise events varied across the 52 visual field points for the delayed (A) and early (B) medication groups. Locations with higher frequency of events are shown in darker background.

Trend-based analysis

In the trend-based analysis, the slopes of pointwise threshold sensitivity varied among individuals from -3.47 to 1.23 dB/year (median: –0.13, IQR: –0.23 to –0.05 dB/year) across the 52 visual field points. The distribution and mean pointwise slopes for each of the 52 visual field points for the early and late medication groups are shown in Fig. 4. In both groups, the mean pointwise slopes were steeper (i.e., more negative) in the nasal and paracentral regions, mainly in the superior hemifield.

Fig. 4. Trend based analysis.

Fig. 4

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Distribution and mean threshold sensitivity rates for each point in the medication (A) and delayed medication groups (B): The distribution of progression slopes within each of the 52 field-points pointwise events varied across the 52 visual field points for the delayed (A) and early (B) medication groups. Locations with a higher frequency of events are shown in darker colours.

Treatment effect

While the general pattern of progression was similar in both groups, the rate of change and frequency of events were higher in the delayed medication group. In the event-based analysis, the average percentage of pointwise events across the 24-2 field was 3.3 ± 1.2% in the delayed medication group, significantly greater compared to 2.3 ± 1.0% in the early medication group (P < 0.001). A similar finding was also observed in the trend-based analysis with faster progression (i.e., more negative) in the delayed treatment on all points (Table S1). Overall, the mean pointwise slopes were significantly (P = 0.007) more negative in the delayed treatment group (–0.16 ± 0.025 dB/year) than in the early treatment group (–0.15 ± 0.020 dB/year).

The differences between the two groups in terms of proportion and slopes of pointwise progression are depicted in Fig. 5. As can be appreciated in both analyses, the difference was most profound at VF locations within the nasal and paracentral regions, comparable with points found to be most vulnerable to progression in the previous section.

Fig. 5. Treatment effect.

Fig. 5

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Differences in rates of change (A) and frequency of pointwise events (B): The difference between the delayed and early medication groups in rates of change (A) and frequency of events (B) for each of the 52 points of the 24-2 visual field. Locations with higher frequency of event are shown in darker colours.

Discussion

This study aimed to determine which 24-2 VF grid locations change most rapidly and frequently in eyes with OHTN. As the schematic structural model predicted, in both the delayed and early medication groups of the OHTS, the nasal and paracentral regions were found to be most vulnerable to progression, corresponding to the IVZ and SVZ of the optic disc. Our findings were consistent with both the trend and event analyses and are in agreement with previous reports on the most common locations of VF defects in early glaucoma [24].

The appearance of an isolated, asymmetric scotoma in the peripheral nasal region, commonly referred to as the “nasal step,” has been described previously and is considered a common feature of early glaucomatous damage [25–27]. The presence of paracentral scotoma in the early stages of the disease has also been described [28–30]. Using conventional thresholding white-on-white perimetry with regionally enhanced spatial resolution, Schiefer et al. found a paracentral defect in over 50% of glaucoma eyes with predominantly mild to moderate field loss [31]. Heijl and Lunqvist used supralinimal threshold-related screening technique to determine the most frequent locations of new defects in OHTN eyes [32]. Out of a cohort of 2907 eyes, 45 developed new defects and those occurred most frequently in the nasal and paracentral regions. However, to our knowledge, the frequency and progression rates for each of the 24-2 VF points during the transition from a normal field to a confirmed glaucomatous defect have not been reported.

The pointwise analysis we applied was chosen to maximize sensitivity for progression detection. In the OHTS, progressive VF damage endpoints were defined by event-based criteria based on reproducible abnormal summary metrics (e.g., glaucoma hemifield test [GHT] result of Outside Normal Limits or a corrected pattern standard deviation [CPSD] with a p-value < 5%). These criteria were mainly devised to provide high specificity and had to be confirmed by an Endpoint Committee. However, it can easily miss early focal changes and obscure progression patterns [33]. Also, the abnormalities were defined based on comparison to age-matched controls rather than an intrasubject longitudinal variability, which might have affected the observed incidence of progressive VF changes. On the one hand, participants whose VF sensitivities were closer to the lower boundaries of abnormality were more likely to develop the OHTS VF endpoint, leading to confirmed VF abnormalities by even small amounts of subsequent deterioration. On the other hand, eyes or test locations with higher VF threshold sensitivity at baseline required more significant loss or needed to be followed for longer periods of time to reach the endpoint.

The novel approach used herein for pointwise detection of progression has several advantages for the detection of patterns of progression. First, the process is automated and objective, eliminating the risk of subjective interpretation and providing a reliable measure of the changes in VF over time. Second, the pointwise analysis offers an exact and detailed measurement of the VF with progression endpoints determined by the individual patient’s change in threshold sensitivity and is not subject to comparison with a normative database. This allows accurate detection of subtle progressive changes in the VF, which may not be noticeable when relying on overall averages or generalized trends subjected to the population variability. Third, the technique enabled us to summarize the progression events and trends for each point on the VF. This provided an overview of the patterns of overall changes in VF loss throughout the entire study population over time. It is important to note that this method was used here with the sole purpose of identifying patterns of VF progression. The graphical approach also does not consider inherent variability in the slope parameters and may have inflated the apparent differences between locations. While this approach provided helpful insights regarding the patterns of progression, our ability to draw conclusions regarding the clinical significance of such differences is limited. The present study also did not address whether the amount of VF change detected has significant implications on vision-related quality of life, nor did it aim to compare these methods with other alternative endpoints in terms of sensitivity and specificity. Specifically, the linear regression models, used for the trend analysis, may not be ideal. Although Pathak et al. [34]. have found that for shorter sequences of tests, and within the high sensitivity range, linear models are non-inferior to other non-linear models, other approaches might be better suited in describing the rate of change over extended follow-up, particularly in the delayed treatment group where rates of change may vary pre- and post-initiation of treatment. While our findings are supported by previous reports as well as the consistency of two independent approaches, we encourage future studies to validate our findings with other models for trend analysis (e.g., cluster analysis or permutation analysis), and to determine the clinical significance of these findings.

As the structural model predicted, the progression was most apparent in the nasal and paracentral field points. These progression patterns were consistent in both the trend and event progression analyses. Each method we used to determine progression has its strengths and weaknesses. The event-based analysis is helpful for detecting rapid, stepwise changes in loss of threshold sensitivity. In contrast, the trend-based analysis is useful for detecting slow, sustained progression, albeit some milder acute changes could be missed. This is especially true for eyes with long stable history during follow-up in which the trend is flat over long period of time and eventually experience a sudden decline in threshold sensitivity, which may not be sufficient to change the steepness of the slope. In such cases, only substantial changes over time will significantly affect the overall trend. Despite these differences, overall, the patterns of VF threshold sensitivity loss were very similar in both approaches, further confirming our hypothesis.

IOP lowering mainly affects the vulnerability regions

The benefits of IOP lowering in glaucoma treatment are well established when comparing patients/eyes undergoing different types of treatment. Multiple prospective randomized controlled studies have shown that a reduction in IOP reduces the rate of progression and VF loss [35–37]. The data collected in the OHTS demonstrated that the risk for the transition from OHTN to POAG could be reduced by lowering IOP [8], a finding supported by similar studies [38–40]. This reduction was also evident with delayed treatment, although there is evidence that the protective effect is greater with early treatment, especially among high-risk individuals [41]. De Moraes et al. used pointwise linear regression analysis to compare the rates of VF change before and after initiation of treatment among participants initially randomized to the observation arm of the OHTS [13]. They found that initiation of treatment resulted in a significant reduction of both the rate of MD change (from -0.17 ± 0.6 dB/year to -0.01 ± 0.5 dB/year, P < 0.01) and number of VF test points that significantly progressed (1.53 ± 5.1 vs. 0.64 ± 2.7, P < 0.01). Our analysis supports these findings and provides additional information on the positive effect of ocular hypotensive treatment. Specifically, we observed slower pointwise progression rates in the early treatment group compared to delayed treatment, and the differences were slightly more apparent in the nasal and paracentral visual field points. The findings were also consistent with the event-based analysis. Supported by previous observations regarding the areas of vulnerability, our results suggest that providing hypotensive treatment to slow down the rate of glaucoma progression, might be more effective in the vulnerability zones, at least at the early stages of the disease.

Limitations

Although the findings of this study offer valuable insights into glaucoma progression, it is important to acknowledge some limitations. First, our results are based on progression patterns among ocular hypertensive patients, most of whom did not develop manifest glaucoma, according to the OHTS criteria [8, 10, 12], during the study period. This could have affected the average progression rates, possibly affecting the pattern of progression as well. Specifically, the fact that all subjects received treatment (either early or delayed) suggests that the natural history might differ. The slopes found in the trend-based analysis might not be purely due to glaucomatous damage from OHTN and might also be affected to a certain degree by normal, age-related decline in VF pointwise sensitivity. However, as the age-related changes are expected to be homogenous throughout the VF, this should not influence the points that would be found most vulnerable. We should also consider that the OHTS findings do not necessarily reflect the progression patterns in the given individual. Although the SVZ and IVZ represent a relatively small (45°) region of the disc, defects in these regions can still vary in location, depth, and width, as well as homogeneity. Thus, the corresponding VF defects seen on a 24-2 VF can show a wide range of patterns [12]. Nevertheless, as expected, on average, the points selected by the model were found to be more likely to progress. In addition, our findings are consistent with typical patterns of VF loss among glaucoma patients. It should also be noted that our distribution of slopes corresponds to the average slope at each location and assumes a similar variability across the visual field. Although our data confirms that this variability is indeed relatively similar between locations, one needs to consider the possibility of some small differences in variability between locations based on eccentricity when interpreting the figures Second, our analysis of patterns of VF loss was bounded by the data obtained in the OHTS. Since the study did not include testing directed at the central VF (e.g., 10-2 standard automated perimetry), our ability to ascertain the patterns of loss in the macular region was limited. Specifically, the low resolution of the 24-2 in the central 10 degrees of the VF might have resulted in greater variability obscuring the progression in this region. While our findings indicate that IOP lowering mainly reduces the rate of progression in the vulnerability zones, the exact relationship between baseline IOP, the degree of IOP lowering, and patterns of progression need to be clarified and warrant further investigation. Lastly, it would have been interesting to confirm our functional findings with changes in the RNFL and GCL over time. Unfortunately, structure-function conformation is limited by the lack of OCT scans in the OHTS.

Summary

Based on the structural model of the areas of vulnerability at the disc, we hypothesized that VF loss would be commonly seen in the nasal and paracentral regions among OHTN patients. The agreement between the two independent pointwise analyses applied to data collected during the first two phases of the OHTS indicate that our hypothesis was correct. In addition, our comparison between the early and delayed treatment groups suggests that it might be possible to slow down the rate of progression in these vulnerability regions with ocular hypotensive treatment. While further studies are needed to validate these findings and evaluate their clinical significance, it seems that it might be prudent to carefully monitor these locations to facilitate early detection of progression and that timely treatment may help reduce the rate of progression in these locations.

Summary

What was known before

  • Ocular hypertension is a known risk factor for developing glaucoma and its progression.

  • The damage most commonly occurs within Certain regions around the optic disc which have been found to be particularly vulnerable.

What this study adds

  • We describe the pattern of glaucomatous visual field loss by identifying the locations on the 24-2 visual field grid that progress most rapidly and frequently among individuals with ocular hypertension.

  • The pattern of functional progression is consistent with the structural model.

Supplementary information

Table S1 (18.3KB, docx)
Figure S1 (2.3MB, tif)
Figure S2 (1.9MB, tif)
Figure S3 (3.4MB, tif)
Figure Legends (13.6KB, docx)

Author contributions

Conceptualization: NB, CGDM, JML; Data curation: NB, CGDM, JML, MOG, MAK; Formal analysis: AL, CGDM, NB; Investigation: AL, CGDM, JML, NB; Methodology: AL, JML, CGDM, MOG, MAK, GAC; Project administration: AL, JML, CGDM; Resources: GAC, CGDM and JML; Supervision: JML, GAC and CGDM; Validation: CGDM, MOG, MAK, GAC, JML; Writing – original draft: AL, JML, NB, CGDM; Writing - review & editing: AL, JML, NB, MOG, MAK, GAC, JML.

Funding

Supported in part by the Jane and David Walentas Glaucoma Research Fund, Columbia University Department of Ophthalmology; an unrestricted grant to the Department of Ophthalmology, Columbia University Department of Ophthalmology from Research to Prevent Blindness, Inc., New York, NY USA; and Schur Family Glaucoma Fellowship (AL), Columbia University Department of Ophthalmology.

Data availability

Data is available and will be provided upon reasonable request.

Competing interests

Carlos G. De Moraes: Carl Zeiss Meditec, Inc. (C); Novartis (C); Heidelberg Engineering (R); Topcon (F); Galimedix (C); Perfuse Therapeutics (C); Ora Clinical, Inc. (E) Jeffrey M. Liebmann: Novartis (R), Alcon (C), Allergan (C), Genentech (C), Thea (C).

Footnotes

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

The online version contains supplementary material available at 10.1038/s41433-024-02949-x.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1 (18.3KB, docx)
Figure S1 (2.3MB, tif)
Figure S2 (1.9MB, tif)
Figure S3 (3.4MB, tif)
Figure Legends (13.6KB, docx)

Data Availability Statement

Data is available and will be provided upon reasonable request.

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