Visual Field Staging Systems in Glaucoma and the
Activities of Daily Living
KAUSHAL M. KULKARNI, JASON R. MAYER, LUCIANO L. LORENZANA, JONATHAN S. MYERS, AND
GEORGE L. SPAETH
PURPOSE: To compare 8 clinically relevant methods of
staging visual field (VF) damage in glaucoma with a
performance-based measure of the activities of daily
living and self-reported quality of life.
DESIGN: Prospective cross-sectional study.
METHODS: One hundred ninety-two patients with var-
ious types of glaucoma were evaluated at the Wills Eye
Institute using standard monocular and binocular VF
testing, as well as an objective, performance-based mea-
sure of visual function (the Assessment of Disability
Related to Vision), and a subjective, standardized mea-
sure of quality of life (the 25-item National Eye Institute
Visual Function Questionnaire). Binocular VFs were
scored according to the Esterman and Integrated VF
Systems. Monocular VFs were scored according to the
mean defect, pattern standard deviation, Hodapp-Par-
rish-Anderson method, glaucoma staging system, glau-
coma staging system 2, and the field damage likelihood
scale. Partial Spearman correlations between VF staging
systems, Assessment of Disability Related to Vision
scores, and 25-item National Eye Institute Visual Func-
tion Questionnaire scores were calculated.
RESULTS: Assessment of Disability Related to Vision
scores and 25-item National Eye Institute Visual Func-
tion Questionnaire scores were associated most closely
with the VF score in the better eye and the binocular VF
scoring systems.
CONCLUSIONS: The amount of binocular VF loss and
the status of the better eye most accurately predict
functional ability and quality of life in glaucoma. (Am
J Ophthalmol 2012;154:445 451. 2012 by Elsevier
Inc. All rights reserved.)
P
HYSICIANS AND PATIENTS ALIKE WANT TO TRANS-
late clinical findings into useful and relevant infor-
mation. Various methods in various disciplines have
approached this issue, with results such as the Apgar
method of estimating clinical relevance of cardiac abnor-
malities in infants.1 In the field of glaucoma, different
Supplemental Material available at AJO.com.
Accepted for publication Mar 20, 2012.
From the William and Anna Goldberg Glaucoma Service and Re-
search Laboratories, The Wills Eye Institute/Jefferson Medical College,
Philadelphia, Pennsylvania (K.M.K., J.R.M., L.L.L., J.S.M., G.L.S.).
Inquiries to Kaushal M. Kulkarni, Bascom Palmer Eye Institute, 900
NW 17th Street, Suite 450, Miami, FL 33139; e-mail: kaushal.kulkarni@
gmail.com
0002-9394/$36.00 2012 BY ELSEVIER INC. ALL
http://dx.doi.org/10.1016/j.ajo.2012.03.030
methods of staging the amount of visual field (VF) loss
have been proposed for the purposes of prognosticating,
monitoring, and treating disease progression and of esti-
mating the effect of the visual loss on the patients health
and quality of life (QoL).2
With regard to the latter, relating visual loss to health,
it seems intuitively likely that the greater the loss of vision,
the greater the effect on the persons health; however, this
is not always the case. Health is related mainly to 2
issuesfunction and feelingthat is, objectively to what
the person can do and subjectively to how well the person
feels.
The present study concerns itself with how well different
methods of scoring (staging) the amount of VF loss in
patients with glaucoma correlate with what people can
actually do and with how they actually feel. It may be that
one of those staging systems works better in this regard
than the others. If such a method or staging system were
identified, it would make sense to use that particular
system to monitor glaucoma patients. However, although
glaucoma has been well characterized, and it is known that
VF loss generally causes impairment in a persons day-to-
day functioning,3 little is known about the actual quanti-
tative impact that VF loss has on a patients QoL and
ability to perform activities of daily living (ADLs).4
Systematic investigation into assessing a patients func-
tional disability has been an intense area of interest in
medicine over the past several years,5 and in glaucoma,
tools for measuring QoL and functional disability have
been developed and refined over the last decade.6,7 Most
studies have attempted to assess this impact through
questionnaires and self-report. However, there are obvious
methodologic limitations for such instruments, and phys-
ical performance-based assessments clearly offer several
advantages over self-report instruments.6 11 Therefore, an
individuals ability to function in daily life, particularly
with respect to visual tasks, increasingly is being assessed
using standardized, performance-based measures of func-
tion performed in a clinical setting4,8,9,1218; these have
been shown to correlate with functional ability at home.18
The purpose of the present study was to compare 8
different methods of staging VF loss using (1) an objective
measure of function, the Assessment of Disability Related
to Vision (ADREV), and (2) a subjective measure of
feeling, the 25-item National Eye Institute Visual Func-
RIGHTS RESERVED. 445
tion Questionnaire (NEI-VFQ 25) as the gold standards
against which the 8 systems were judged.
METHODS
SUBJECTS: Eligible patients signed an informed consent
form before enrollment in the study. All subjects were
established patients on the Glaucoma Service of the Wills
Eye Institute. Approximately 2000 charts of all patients
returning for examination during the period of the study
(March 2006 through December 2006) were screened
consecutively for possible inclusion. Before starting enroll-
ment, a prospective plan for selecting patients was de-
signed to assure inclusion of cases with the full range of VF
loss (from none to far advanced), with approximately equal
numbers of cases with various stages of glaucomatous field
loss representing the entire spectrum of glaucomatous
damage.
Exclusion criteria included the inability to understand
and respond to spoken English, incisional eye surgery
within the previous 3 months, laser treatment within the
previous 1 month, presence of cataract (Lens Opacities
Classification System II grade 2 or more), or presence of
significant neurologic, motor, or other comorbidity that
might have prevented the patient from completing the
study. Patients who had primary open-angle glaucoma,
primary angle-closure glaucoma, normal-tension glau-
coma, pseudoexfoliative glaucoma, pigmentary glaucoma,
inflammatory glaucoma, neovascular glaucoma, angle re-
cession glaucoma, and plateau iris syndrome glaucoma
were included in the study.
Of the patients who were considered eligible for inclu-
sion, 50 declined to participate because of the time
required. Although 200 subjects agreed to participate and
started the study, 6 did not complete the project, all
because of time constraints. No patients with ocular
hypertension were included in the present study.
CLINICAL EVALUATION: All participants received a
standard examination as part of their routine ophthalmic
clinical care before giving their informed consent. Visual
acuities (monocular and binocular) were measured using
the Lighthouse Early Treatment Diabetic Retinopathy
Study Distance Visual Acuity Test, 2nd edition. Visual
acuity was measured with the patients present, walk-in,
refractive correction and was scored by counting how
many letters were read correctly and converting this value
to logarithm of the minimal angle of resolution units. Each
participant also underwent monocular VF testing in each
eye with an automated perimeter (Humphrey Visual Field
Analyzer II; Humphrey Instruments, San Leandro, Califor-
nia, USA) using the 24-2 Swedish interactive threshold
algorithm standard program, and binocular VF testing
using the Esterman program. An appropriate corrective
lens was used in all cases, based on the patients refractive
446 AMERICAN JOURNAL
correction for distance, modified for the patients age or
lens status. Patients did not perform new VF tests if they
had been tested fewer than 6 months before the study using
the same strategy. Binocular contrast sensitivity was mea-
sured at 1 m using the Pelli-Robson contrast sensitivity
chart and protocol.19 All patients completed the NEI-VFQ
25 QoL survey.20
VISUAL FIELD SCORING: For each of the 192 patients,
each monocular VF result was scored according to the
following staging systems: (1) the Hodapp-Parrish-Ander-
son score (ordinal, 0 through 4),21 (2) the Field Damage
Likelihood Scale (ordinal, 0 through 7),22 (3) the Glau-
coma Staging System (ordinal, 0 through 5),23 (4) the
Glaucoma Staging System 2 (ordinal, 0 through 5),24 (5)
the Humphrey Visual Field Analyzer II mean defect (MD;
30 through 2 dB), and (6) the Humphrey Visual Field
Analyzer II pattern standard deviation (0 through 15).
Fields were also staged according to 2 binocular systems.
One of these was the Integrated Visual Field (IVF) system
described by Crabb and associates (ordinal, 0 through
104).25 Each location in the right monocular VF has a
corresponding point in the left monocular field in binoc-
ular viewing. The maximum raw sensitivity from each of
the 2 overlapping locations is then plotted to create a grid
of sensitivity values, representing the IVF. Next, each of
the 52 points that make up the IVF is considered in turn.
A point is scored 0 if it exhibits a measured threshold of 20
dB or better, a point is scored 1 if it has a threshold
between 10 and 19 dB, and a point is scored 2 for a
threshold of less than 10 dB. The scores at each point are
added across the whole of the IVF, giving a summary value
of the damage across the field: a completely defective
integrated VF results in an IVF score of 104, whereas a
normal, unaffected integrated VF yields an IVF score of 0.
The other binocular VF test was the Esterman program,
which was recorded as the Esterman Binocular Disability
Score (ordinal, 0 through 100).26
If a patient was unable to complete monocular auto-
mated VF testing in the worse eye because of poor vision,
an MD score of 30 dB and a pattern standard deviation
of 15 were given for that eye, and that eye was assigned the
worst clinical stage (4, 7, 5, and 5) within the Hodapp-
Parrish-Anderson, Field Damage Likelihood Scale, Glau-
coma Staging System, and Glaucoma Staging System 2
staging systems, respectively. Additionally, when calculat-
ing the IVF score, each of the points in such eyes was
considered to have a sensitivity value of less than 10 dB.
The better eye was defined as the eye with the better
overall VF sensitivity, as determined by MD.
THE ASSESSMENT OF DISABILITY RELATED TO VISION
TEST: Tasks included in the ADREV test were based on a
second-generation performance-based measure, the Assess-
ment of Function related to Vision.12 The Assessment of
Function Related to Vision instrument validated 5 tests of
OF OPHTHALMOLOGY SEPTEMBER 2012
performance of visually intensive tasks based on item
response theory in the form of Rasch analysis and significant TABLE 1. Baseline Characteristics of Patients Included in
relationships with both traditional clinical measures of oph- the Assessment of Disability Related to Vision Study
Assessing Visual Field Staging Systems in Glaucoma and
thalmic status, as well as self-reported vision-specific QoL the Ability to Perform Activities of Daily Living
measured by the NEI-VFQ 25. The instrument used within
the context of this investigation, titled the ADREV, was Age (years)
developed based on the findings of the Assessment of Func- Mean standard deviation 67.1 12.9
tion Related to Vision experiment, and the details of its Range 24 to 93
design have been documented elsewhere.8,13,14 Sex
Male 96 (50%)
Briefly, the ADREV comprises 9 tests, including: read-
Female 96 (50%)
ing in reduced illumination, facial expression recognition,
Race
computerized motion detection, recognizing street signs, European American 107 (55.7%)
locating objects, ambulation, placing a peg into different- African American 78 (40.6%)
sized holes, telephone simulation, and matching socks. A Hispanic 3 (1.5%)
description of each test item is presented in the Supple- Asian 3 (1.5%)
mental Appendix. Each test of performance is graded from Other 1 (0.5%)
0 through 7 on an interval scale determined through Rasch Type of glaucoma
Primary open-angle glaucoma 140 (72.9%)
analysis, where 0 represents the inability to perform the
Primary angle-closure glaucoma 15 (7.8%)
test and 7 indicates a perfect score. In addition to the Normal-tension glaucoma 13 (6.7%)
subscale evaluations, the 9 tests are summed to produce a Pigmentary glaucoma 7 (3.6%)
total ADREV score ranging from 0 to 63. The subscales Pseudoexfoliative glaucoma 7 (3.6%)
can be used and interpreted independently from the Inflammatory glaucoma 5 (2.6%)
ADREV total score. Average test administration time, Neovascular glaucoma 2 (1.0%)
including patient instruction, is approximately 30 minutes. Angle recession glaucoma 2 (1.0%)
Plateau iris syndrome 1 (0.5%)
The ADREV was validated previously in a study popula-
tion involving patients with age-related macular degener-
ation and diabetic retinopathy through comparison with
standard clinical measures of visual function and self- The average test administration time for the VFQ is
reported QoL.8,14 approximately 10 minutes.
The tasks were performed with both eyes open and with
the subjects wearing their present habitual refractive cor- STATISTICAL ANALYSIS: Patient demographics were
rection. All 9 tasks were performed under ambient lighting analyzed using descriptive statistics. Partial Spearman cor-
(range, 35 to 40 foot candles), except for reading in relations adjusting for age, race, and visual acuity were used
reduced illumination, facial expression recognition, and to compare scores from each of the ADREV subtests with
computerized motion detection, all of which were tested in each of the VF staging systems. We also calculated corre-
a dark room. Patients also were required to open 3 padlocks lations between the total ADREV score and each of the
of different sizes with 3 different keys. This particular test VF staging systems. P values were adjusted using the
does not seem to be related to visual ability; it was used to method of Benjamini and Hochberg to account for multi-
detect malingering and was not included in calculating the ple testing and to control the false-discovery rate at 5%.
final ADREV score. Statistical significance was defined as P .05. Each of the
The NEI-VFQ 25 survey was administered to each VF staging systems was compared with the total NEI-VFQ
subject.20 The NEI-VFQ 25 was selected as the studys 25 score in a similar manner.
primary QoL measurement because it is accepted as a
reliable and valid means of studying the self-perceived
impact of visual impairment on vision-specific QoL.20 The
NEI-VFQ 25 comprises 11 vision-specific subscales that
address the following domains: general vision, near vision, RESULTS
distance vision, ocular pain, social functioning, mental
health, role difficulties, dependency, driving, color vision, THE BASELINE AND DEMOGRAPHIC DATA FOR THE ADREV
and peripheral vision. Each subscale is scored from 0 to study have been reported previously.13 Table 1 summarizes
100, where 100 represents self-perceived perfect function- these results. Partial Spearman correlations adjusted for
ing and 0 represents the greatest level of difficulty in a age, race, and visual acuity revealed that scores in the
given domain. The 11 subscales also are averaged to better eye have a closer relationship with total ADREV
produce a VFQ total score ranging from 0 through 100. score than scores in the worse eye; this was true across all

VOL. 154, NO. 3 VISUAL FIELD STAGING SYSTEMS 447

 TABLE 2. Visual Field Staging System Scores versus Itemized Assessment of Disability Related to Vision Scores Assessing
Correlations between Visual Field Staging Systems in Glaucoma and the Ability to Perform Activities of Daily Living

Readinga Expressionsb Motionc Street Signsd Objectse

Partial Partial Partial Partial Partial

Spearman Spearman Spearman Spearman Spearman
VF Staging System Correlations P Value Correlations P Value Correlations P Value Correlations P Value Correlations P Value

IVF 0.14 0.09 0.10 .45 0.37 .001 0.16 .07 0.36 .001
MD better eye 0.18 0.06 0.07 .51 0.37 .001 0.19 .05 0.33 .001
HPA better eye 0.15 0.08 0.06 .52 0.31 .001 0.18 .05 0.27 .001
Esterman 0.17 0.06 0.04 .69 0.36 .001 0.08 .49 0.33 .001
GSS better eye 0.21 0.06 0.09 .45 0.27 .001 0.20 .05 0.36 .001
GSS2 better eye 0.14 0.10 0.10 .45 0.34 .001 0.12 .25 0.28 .001
FDLS better eye 0.16 0.08 0.10 .45 0.28 .001 0.16 .07 0.29 .001
MD worse eye 0.18 0.06 0.09 .45 0.34 .001 0.05 .65 0.29 .001
GSS worse eye 0.08 0.31 0.11 .45 0.36 .001 0.01 .86 0.24 .002
GSS2 worse eye 0.16 0.08 0.07 .51 0.29 .001 0.02 .86 0.19 .01
PSD better eye 0.06 0.42 0.03 .69 0.15 .04 0.07 .49 0.19 .01
HPA worse eye 0.13 0.12 0.08 .45 0.23 .002 0.04 .65 0.16 .03
FDLS worse eye 0.06 0.42 0.10 .45 0.24 .001 0.04 .65 0.14 .06
PSD worse eye 0.02 0.80 0.02 .82 0.11 .13 0.11 .25 0.04 .58

Ambulationf Peg & Holesg Telephoneh Matching Socks Total ADREV

Partial Partial Partial Partial Partial

Spearman Spearman Spearman Spearman Spearman
VF Staging System Correlations P Value Correlations P Value Correlations P Value Correlations P Value Correlations P Value

IVF 0.38 .001 0.16 .09 0.28 .001 0.44 .001 0.49 .001
MD better eye 0.34 .001 0.17 .08 0.26 .002 0.40 .001 0.47 .001
HPA better eye 0.35 .001 0.14 .11 0.27 .001 0.38 .001 0.46 .001
Esterman 0.37 .001 0.18 .08 0.22 .005 0.37 .001 0.44 .001
GSS better eye 0.33 .001 0.17 .08 0.22 .005 0.36 .001 0.44 .001
GSS2 better eye 0.33 .001 0.12 .22 0.22 .01 0.39 .001 0.43 .001
FDLS better eye 0.29 .001 0.16 .09 0.21 .01 0.35 .001 0.42 .001
MD worse eye 0.34 .001 0.12 .21 0.23 .003 0.35 .001 0.40 .001
GSS worse eye 0.30 .001 0.04 .69 0.14 .06 0.31 .001 0.33 .001
GSS2 worse eye 0.31 .001 0.03 .77 0.25 .002 0.31 .001 0.33 .001
PSD better eye 0.24 .001 0.07 .43 0.14 .07 0.24 .001 0.27 .001
HPA worse eye 0.28 .001 0.00 .99 0.14 .06 0.24 .001 0.26 .001
FDLS worse eye 0.18 .01 0.02 .86 0.11 .13 0.25 .001 0.22 .001
PSD worse eye 0.10 .17 0.09 .33 0.05 .50 0.17 .02 0.08 .29

ADREV Assessment of Disability Related to Vision; Esterman Esterman Binocular Disability Score; FDLS Field Damage Likelihood
Scale; GSS Glaucoma Staging System; GSS2 Glaucoma Staging System 2; HPA Hodapp-Parrish-Anderson score; IVF integrated
visual field; MD mean defect; PSD pattern standard deviation.
a
Reading in reduced illumination.
b
Facial expression recognition.
c
Computerized motion detection.
d
Recognizing street signs.
e
Locating objects.
f
Ambulation test.
g
Placing a peg into different sized holes.
h
Telephone simulation.

of VF staging systems (Table 2). The system that showed
the highest correlation with the total ADREV score was
the IVF score (0.49; P .001) although the superiority
was not statistically greater than the correlation with
several other methods, specifically, MD in the better eye
(0.47; P .001) and the Hodapp-Parrish-Anderson score
in the better eye (0.46; P .001), with the Esterman
and other VF staging systems in the better eye following
closely behind (Table 2).
A similar pattern was seen when comparing the various
VF staging systems with NEI-VFQ 25 scores. Partial
Spearman correlations showed scores in the better eye

448 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER 2012

 functional performance on visual tasks and self-reported
TABLE 3. Visual Field Staging System Scores versus Total QoL. Our study found that correlations between VF scores
25-Item National Eye Institute Visual Function and ADREV scores were highest for the IVF and scores in
Questionnaire Scores Assessing Visual Field Staging
Systems in Glaucoma and the Ability to Perform Activities
the better eye across all staging systems (Table 2). Simi-
of Daily Living larly, correlations between VF scores and NEI-VFQ 25
scores were highest for MD in the better eye and the IVF
VF Staging System Partial Spearman Correlation P Value (Table 3). Correlations with the worse eye were far weaker
MD better eye 0.42 .0001 for all staging systems when compared with both total
IVF 0.41 .0001 ADREV score and NEI-VFQ 25 score. These results are in
GSS2 better eye 0.40 .0001 rough agreement with previous works reporting that MD in
MD worse eye 0.39 .0001 the better eye and binocular VF loss correlate most closely
GSS2 worse eye 0.38 .0001
with self-reported difficulties in performing ADLs.27,29,30
Esterman 0.37 .0001
These findings also suggest that with regard to functional
HPA better eye 0.37 .0001
GSS better eye 0.36 .0001
assessment, simply measuring MD in the better eye, which
HPA worse eye 0.34 .0001 is readily available on most perimeters and does not require
FDLS better eye 0.30 .0001 complex calculations or formulas, seems to be as useful as
GSS worse eye 0.29 .0001 other, more complicated schemes of staging. Additionally,
FDLS worse eye 0.26 .0004 it seems that pattern standard deviation has poor value in
PSD better eye 0.23 .0013 predicting a patients visual function status.
PSD worse eye 0.13 .078
These results confirm the findings of previous ADREV
Esterman Esterman Binocular Disability Score; FDLS
studies, in which binocular and better-eye visual acuity
Field Damage Likelihood Scale; GSS Glaucoma Staging were most closely related to ADREV scores in patients
System; GSS2 Glaucoma Staging System 2; HPA Hodapp- with diabetic retinopathy and age-related macular de-
Parrish-Anderson score; MD mean defect; PSD pattern generation.8,14 Furthermore, the diabetic retinopathy
standard deviation; VF visual field. population, with peripheral VF loss after pan-retinal pho-
tocoagulation, also showed a significant relationship be-
having a closer relationship with NEI-VFQ 25 scores than tween ADREV total and subscale performance and better
scores in the worse eye; again, this was true across all VF eye VF.14 Thus, although knowledge of the visual status of
staging systems (Table 3). The systems that showed the the worse eye is important in determining the amount of
highest correlation with NEI-VFQ 25 score were, again, change in the eye, its status does not seem to be as
MD in the better eye (0.42; P .001) and IVF (0.41; important as binocular considerations, or, importantly,
P .001; Table 3). merely the status of the better eye in determining actual
The ADREV subtests that showed the greatest number functional ability.
of statistically significant correlations with VF scores were Many authors have evaluated different systems for char-
matching socks, the ambulation test, computerized motion acterizing monocular and binocular VF loss,2 resulting in
detection, finding objects, and telephone simulation. numerous staging systems at the clinicians disposal. Many
of these systems have been designed for research and
investigational purposes. In this study, we focused on those
DISCUSSION staging systems that we believe are clinically relevant, yet
do not require complicated calculations or software. How-
THIS PROSPECTIVE OBSERVATIONAL STUDY OF 192 GLAU-
ever, a limitation of the present study is that the 8 staging
coma patients exhibiting the full range of VF loss was
systems included here differ in that some contain contin-
designed to compare the relationships between several VF
staging systems in glaucoma with the actual ability of uous scales, whereas others are categorical. This difference
patients to perform the ADLs and with self-reported QoL. alone may affect the strength of the statistical correlations.
Several previous articles have attempted to evaluate this Further limitations of using a performance-based test
relationship using standardized questionnaires to evaluate such as ADREV been described previously.8,1215 Specifi-
QoL or perceived ability to perform activities6,7,27; how- cally, although the activities chosen for the ADREV are
ever, to our knowledge, few studies objectively have encountered commonly in daily living, not all individuals
observed glaucoma patients performing activities in a will perform these activities or will value them to the same
standardized clinical setting.8,1217,28 extent. Similarly, the ADREV test purposely was not
Traditionally, monocular VFs have been used in both timed; patients were scored solely based on the number of
the detection and follow-up of glaucoma; although mon- items performed correctly, regardless of the time it took to
ocular field tests are necessary to assess each eyes clinical perform the task. It has been shown that the time needed
status, it is the better eye that seems more closely related to by older adults successfully to perform instrumental ADLs

VOL. 154, NO. 3 VISUAL FIELD STAGING SYSTEMS 449

is linked to the level of visual function, independent of the
effects of general health, education level, and depression.28
It is clear that there are a myriad of factors that may
account for the wide range of functional ability seen in
individuals with similar amounts of clinical disability; for
example, cognitive, emotional, and psychosocial factors
certainly influence an individuals performance on visual
tasks in the clinical setting, as does duration of vision loss
and VF loss. Further investigation into the exact influence
of these factors on visual task performance is warranted.
We believe the present study takes an important step
toward identifying staging systems that best identify the effect
of VF changes in glaucoma on a patients ability to perform
ADLs. It seems that the status of the better eye provides as
much useful information with regard to visual functioning as
more complex, more time-consuming methods. However, the
factors affecting functional disability are difficult to quantify,
and much work remains to be carried out before a full
understand of functional disability can be used to guide the
diagnosis, treatment, and monitoring of glaucoma.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF
interest and the following were reported. Dr Spaeth has received payment for lectures, including service on speakers bureaus, from Merck U.S. Human
Health, Alcon Laboratories, Inc., Pfizer Ophthalmics, and Allergan, Inc. Publication of this article was supported in part by Pfizer (New York, New
York); The Perelman Fund through the Wills Eye Institute of Jefferson Medical College (Philadelphia, Pennsylvania); The Pearle Vision Foundation;
and The Glaucoma Service Foundation to Prevent Blindness, Philadelphia, Pennsylvania, USA. Involved in Design of study (L.L.L., J.S.M., G.L.S.);
Conduct of study (K.M.K., J.R.M., L.L.L., J.S.M., G.L.S.); Data collection (K.M.K., J.R.M., L.L.L., J.S.M., G.L.S.); Data management (K.M.K., J.R.M.,
L.L.L., J.S.M., G.L.S.); Data analysis (K.M.K., L.L.L., G.L.S.); Interpretation of data (K.M.K., L.L.L., J.S.M., G.L.S.); and Preparation, review, and
approval of manuscript (K.M.K., J.R.M., L.L.L., J.S.M., G.L.S.). The Institutional Review Board of the Wills Eye Institute prospectively approved the
protocol for this study. The study was performed with proper informed consent from each patient for participation in the research study. The study was
performed in compliance with the Health Insurance Portability and Accountability Act. The authors thank Benjamin Leiby, Thomas Jefferson
University, for his assistance with the statistical analysis.

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451
 SUPPLEMENTAL APPENDIX:
ASSESSMENT OF DISABILITY RELATED
TO VISION TEST DESCRIPTION
1. Reading in reduced illumination: Near vision is
checked by obtaining the smallest Jaeger line, then 7
sentences, text size corresponding to 2 Jaeger lines
above the smallest Jaeger read, are presented one at a
time. Light illumination is reduced after each sen-
tence is read. The corresponding score is as follows: 1
point able to read at 200 foot candles (FC), 2
points able to read at 150 FC, 3 points able to
read at 100 FC, 4 points able to read at 50 FC, 5
points able to read at 25 FC, 6 points able to
read at 10 FC, and 7 points able to read at 5 FC.
The highest score is 7 and the lowest score is 0.
2. Facial expression recognition: Seven full-face pro-
fessional color photographs of varying sizes and
facial expressions (angry, sad, happy, or surprised)
are presented on a computer screen at a distance of
0.5 m. The patient receives 1 point for recognizing
the right facial expression. The score ranges from 7
to 0.
3. Computerized motion detection: A large black cross
against a white background on a computer screen
provides a point of fixation. While fixating on the
cross, 14 balls of different sizes and colors move
diagonally across the screen, one at a time, from
either the right or the left side at a constant speed.
Yellow, red, or blue balls are used. The patient is
asked to count the number of moving balls. Each ball
seen counts as 0.5 point. The highest score is 7 and
the lowest score is 0.
4. Recognizing street signs: Seven written word signs
ranging from large to small are read at a distance of
4 m. One character in each sign was changed from
familiar phrases, making the word difficult to guess.
For example, the top sign reads SUGAR DANE,
which is similar to the more familiar sugar cane.
The patient is instructed not to guess. One point is
given for each sign read correctly. The highest score
is 7 and the lowest score is 0.
451.e1 AMERICAN JOURNAL
5. Locating objects: Fourteen red and beige boxes of
different sizes are scattered around the testing room
(4 2 m). Sample boxes are shown before test is
begun. The patient attempts to locate the boxes
while seated. Each box found is worth 0.5 point. The
highest score is 7 and the lowest is 0.
6. Ambulation test: A 4.5-m predefined mobility
course was designed, with taped horizontal, vertical,
and diagonal lines and objects made of polystyrene
foam in the path. Several objects also were suspended
from the ceiling along the path. Patients are permit-
ted to use a mobility aid (eg, cane). The score is
based on number of obstacles hit. Each obstacle
successfully avoided was awarded one-third of a
point. The highest score is 7 and the lowest is 0.
7. Placing a peg into different sized holes: Seven (9
3 3/8 inches) wooden boards were created with 1
hole of varying sizes and locations. A wooden stand
was created with slots to hold the boards one at time
at different angles. The patient is asked to place the
peg directly in the hole without touching the board.
One point is awarded for successful completion.
8. Telephone simulation: Seven calculators of different
sizes are used to simulate dialing a telephone. The
numbers are rearranged randomly to eliminate memory
being used to locate the telephone numbers. The
numbers are printed from different font sizes and are
presented to patients from largest to smallest. The
patient is asked to press 7 different numbers on each of
the various sized calculators. The patient must find all 7
numbers to receive 1 point for that calculator. For each
number correctly dialed, the patient receives 1 point.
The highest score is 7 and the lowest is 0.
9. Matching socks: Seven differently patterned, dark-
colored socks are hung on a board with a grey back-
ground. The patients are not permitted to touch the
socks hanging on the wall. The patient sits in front of a
table 1 m wide so as to be 1 m from the socks. On the
table is a group of 10 socks, 7 of which are the pairs for
the hanging socks. The patient is asked to match the
socks on the table with those on the board. One point
is awarded for each correctly matched sock. The highest
score is 7 and the lowest is 0.
OF OPHTHALMOLOGY SEPTEMBER 2012
 Biosketch
Kaushal M. Kulkarni, MD, received his Bachelor of Science degree in Mechanical Engineering from Columbia University,
New York, New York, and earned his medical degree from UMDNJ-Robert Wood Johnson Medical School. He then
completed an ophthalmology residency at Georgetown University/Washington Hospital Center and is currently a fellow
in neuro-ophthalmology at the Bascom Palmer Eye Institute in Miami, Florida.

VOL. 154, NO. 3 VISUAL FIELD STAGING SYSTEMS 451.e2

 Biosketch
George L. Spaeth completed a fellowship in glaucoma at the National Institute of Neurological Diseases & Blindness and
has spent almost his entire career at the Wills Eye Institute, Philadelphia, Pennsylvania. He believes that taking care of
patients well is important, but that passing on knowledge and values to others and trying to answer difficult questions are
equally important. Dr Spaeth has made unparalleled contributions in all of those fields throughout his distinguished and
exemplary career.

451.e3 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER 2012

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.