Glaucoma

Comparison of Visual Field Progression Rates Among the

High Tension Glaucoma, Primary Angle Closure Glaucoma,
and Normal Tension Glaucoma
Shonraj Ballae Ganeshrao,1–3 Sirisha Senthil,1 Nikhil Choudhari,1 Shravya Sri Durgam,1 and
Chandra Sekhar Garudadri1
1
VST Centre for Glaucoma Care, L V Prasad Eye Institute, Banjara Hills, Hyderabad, India
2
Brien Holden Institute of Optometry and Vision Science, Hyderabad Eye Research Foundation, L V Prasad Eye Institute, Banjara
Hills, Hyderabad, India
3
Department of Optometry, School of Allied Health Sciences, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka,
India

Correspondence: Sirisha Senthil,
VST Centre for Glaucoma Care, LV
Prasad Eye Institute (LVPEI), Kallam
Anji Reddy Campus, LV Prasad Marg,
Banjara Hills, Hyderabad 500 034,
India;
sirishasenthil@lvpei.org.
Submitted: August 1, 2018
Accepted: January 16, 2019
Citation: Ballae Ganeshrao S, Senthil S,
Choudhari N, Sri Durgam S, Garudadri
CS. Comparison of visual field pro-
gression rates among the high tension
glaucoma, primary angle closure
glaucoma, and normal tension glau-
coma. Invest Ophthalmol Vis Sci.
2019;60:889–900. https://doi.org/
10.1167/iovs.18-25421
PURPOSE. To compare the visual field (VF) progression among high tension glaucoma (HTG),
primary angle closure glaucoma (PACG), and normal tension glaucoma (NTG) subjects in
routine clinical care.
METHODS. All patients had ‡5 VF tests using HFA, 24-2, SITA-standard strategy. We compared
the progression between glaucoma subtypes after matching the VFs for baseline severity
(mean deviation [MD]) and the age at presentation. Global VF progression was evaluated by
linear regression analysis (LRA) of MD. For local VF progression, scotoma expansion (SE)
defined as appearance of new scotoma and scotoma deepening (SD) defined by pointwise
LRA were calculated. SE and SD were analyzed in three VF zones: superior arcuate (SA),
inferior arcuate (IA), and central (C).
RESULTS. A total of 310 HTG, 304 PACG, and 165 NTG eyes were included. When VFs were
matched by baseline MD, a greater number (n ¼ 20/76) of eyes with HTG showed significant
progression compared to PACG (n ¼ 9/76; P ¼ 0.04). The number of progressing eyes were
not significantly different between HTG and NTG (n ¼ 11/76; P ¼ 0.10) and between NTG
and PACG (P ¼ 0.65). When the baseline VFs were matched by age, the number of eyes
showing significant progression were similar in all the subtypes. SA zone in HTG and NTG
showed greater SE and SD compared to other zones (P < 0.05), whereas IA zone in PACG
showed greater SE and SD compared to other zones (P < 0.05).
CONCLUSIONS. In our cohort of treated primary glaucoma with matched baseline severity, a
greater proportion of HTG eyes progressed faster compared to PACG. SA zone in HTG and
NTG and IA zone in PACG showed greater VF progression.
Keywords: visual field, progression, glaucoma

isual field (VF) progression is the main outcome measure
V for the majority of glaucoma clinical trials.1–6 The mean VF
progression rates for the patients enrolled in these clinical trials
ranged from 0.00 to 1.1 dB/year.3,6–9 Clinical trials usually
have a strict protocol to monitor IOP control, compliance, and
follow-up. However, in regular clinical care, patient’s compli-
ance and follow-up are important determinants for treatment
outcomes. Therefore, the progression rates obtained from
clinical trials may not always reflect the disease course or
progression seen in patients under regular clinic care.
Studies comparing VF progression rates in primary open
angle glaucoma (POAG) patients enrolled in clinical trials and
those under routine clinical care have reported conflicting
results. Chauhan et al.10 reported lower VF progression rate in
clinical care, while Heijl et al.11 reported highly variable VF
progression rates in clinical care. Henson et al.12 reported faster
VF progression in routine clinical care patients compared to
clinical trials.
Majority of these clinical trials had POAG patients, which
was due to a higher prevalence of POAG compared to primary
angle closure glaucoma (PACG) in these study populations.
However, in the South Asian population, the prevalence of
PACG is high and is estimated to contribute to 86% of the
world’s angle closure glaucoma population.13 PACG in the
south Indian population is reported to be as high as POAG.14–18
The existing sparse literature comparing VF progression
rates in different glaucoma subtypes in patients under standard
clinical care has reported similar mean progression rates among
the glaucoma subtypes, without adjusting for baseline severity
and age at presentation.19 However, the progression rates can
be affected by age at presentation and baseline severity.20
Hence evaluating rates of progression by subtypes matched for
baseline severity and age at presentation is important.
Studies have shown different spatial pattern of VF defects
among various glaucoma subtypes; in normal tension glaucoma
(NTG), the VF locations closer to fixation are involved early,
whereas in high tension glaucoma (HTG), the field defects are

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 Visual Field Progression in Subtypes of Glaucoma
FIGURE 1. An example of (A) baseline MD matched triplet and (B) baseline age matched triplet. Legend with (*) represents the fast progressing
subtype of glaucoma.
noted in the arcuate areas.21–25 From a clinical perspective, it is
important to study the pattern of VF defects in glaucoma as
different areas of VF loss would have a different impact on the
vision-related quality of life.26–32
In this study, we analyzed the longitudinal VF data collected
at a tertiary eye care center, with an aim to study the (1) global
VF progression rate in different glaucoma subtypes matched
for baseline severity and age; and (2) to evaluate patterns of VF
progression in different glaucoma subtypes. We choose to
study this in the three primary glaucoma subtypes: the POAG
referred as HTG, PACG, and NTG.
METHODS
This retrospective study was approved by the institutional
review board and followed the tenets of the Declaration of
Helsinki. Patients with a clinical diagnosis of HTG, PACG, and
NTG with five or more VF examinations performed from
January 2000 to December 2012 were included in this study.
Participants in this study were under standard clinical care
by glaucoma specialists. Unlike clinical trials where the
protocol was standardized and the VF examinations were
carried out at regular intervals, the frequencies of VF
examinations were different for different participants. The
frequency with which VF examinations were conducted in our
study varied from 3 months to 2 years. To standardize and for
meaningful comparison, we included VFs that were at least 1
year apart but not more than 2 years apart. Data from both eyes
were included.
All patients underwent comprehensive eye examination
that included IOP measurements using Goldmann applanation
tonometry, four mirror gonioscopy in dark room using Suss-
man lens, dilated fundus examination using 90D lens, VF
TABLE 1. Baseline Parameters, Follow-Up Years, and Median Time Between Follow-up in HTG, PACG, and NTG Subgroups
HTG
Median (IQR)
Parameters (N ¼ 310 eyes)
Baseline age, y 58 (49 to 65)
Baseline MD, dB 8.4 (3.6 to 18.9)
Follow-up, y 10.5 (8.5 to 13.1)
Median time between follow-up, y 1.6 (1.3 to 2.0)
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IOVS j March 2019 j Vol. 60 j No. 4 j 890
examination using HFA, and Swedish Interactive Threshold
Algorithm (SITA) standard test strategy using the 24-2 grid. VF
overview reports were saved in PDF format from Zeiss Forum
software. Using custom written computer program in R
software,33 we extracted the reliability parameters, raw
threshold values, mean deviation (MD), and pattern standard
deviation (PSD) values from the overview reports. VFs that had
false positive, false negative, and fixation loss greater than 33%
were excluded from the analyses. Any patient with a follow-up
period of <5 years or any other ocular diseases other than
cataract were excluded from the study. Patients who under-
went any intraocular surgery (including cataract and glaucoma
filtration surgery) either prior to their presentation to our
institute or during the follow-up period were excluded from
the study. Eyes with with acute angle closure attack were also
excluded. All those included had a minimum number of five
VFs per eye after fulfilling the exclusion criteria.
HTG, PACG, and NTG diagnoses required the presence of
optic nerve head changes characteristic of glaucoma (focal or
diffuse neuroretinal rim thinning, localized notching, or nerve
fiber layer defects) with correlating VF defects. Angle closure
was diagnosed in the presence of occludable angle or closed
angle (posterior trabecular meshwork was not visible in ‡1808
on gonioscopy) with synechiae or elevated IOP > 21 mm Hg
with glaucomatous disc damage. HTG was diagnosed in the
presence of open angles on gonioscopy and IOP greater than
21 mm Hg without treatment. NTG was diagnosed with
features similar to HTG, but with IOP <21 mm Hg on more
than two clinic visits or on diurnal IOP measurements prior to
treatment (of the 212 NTG eyes, 156 eyes had 24-hour diurnal
IOP measurements prior to initiation of treatment and the rest
were diagnosed based on IOP < 21 mm Hg on more than two
clinic visits).
PACG NTG
Median (IQR) Median (IQR)
(N ¼ 304 eyes) (N ¼ 165 eyes) P Value
54 (48 to 60) 57 (50 to 63) 0.22
4.6 (2.2 to 13.0) 7.2 (3.3 to 14.1) 0.003
11.3 (9.1 to 13.4) 9.5 (7.5 to 11.9) 0.05
1.6 (1.3 to 2.0) 1.6 (1.3 to 1.8) 0.49
 Visual Field Progression in Subtypes of Glaucoma IOVS j March 2019 j Vol. 60 j No. 4 j 891

P Value
Our treatment protocol for PACG is to perform laser

0.12
0.98
0.40
peripheral iridotomy (LPI) for all eyes. Following LPI, based
on the post PI IOP, disc damage, and angle opening/
occludability, we initiate treatment. One to 2 weeks post-LPI,

4.8 (2.2 to 12.7) 6.6 (3.3 to 14)

0.32 (0.7 to 0.0)

the VFs are performed. We have excluded eyes with acute

57 (50 to 62)
angle closure attack.
Since we extracted only raw threshold values from
NTG

‘‘overview’’ HFA printouts, the total deviation values, and

pattern deviation values were calculated from ‘‘visualField’’
Baseline Age Matched (N ¼ 106)

packages26 available in R.33 The ‘‘visualField’’ package contains

normative data of 24-2 SITA test strategy. The details of the
normative database are described elsewhere.34 Marı́n-Franch et
Median (IQR)

al.34 have shown that the MD values calculated from this

0.42 (0.7 to 0.0)

normative data set showed good agreement with HFA

57 (50 to 62)

normative data set.

PACG

Definition of Progression
Global VF Progression. To calculate the global VF
progression, we regressed MD values over time. Chauhan et
al.10 used a robust linear regression analysis35 (robust to the
7.3 ( 3.1 to 188.0)

outliers) to calculate VF progression in large clinic populations.

0.24 (0.7 to 0.0)

We also adopted robust linear regression to calculate the

57 (50 to 62)

slopes. We matched VFs for age and glaucoma severity (MD) at

HTG

presentation. A custom built computer program automatically

TABLE 2. Showing Baseline MD, Age, and Rate of MD Progression for Baseline MD Matched Triplets and Age Matched Triplets

selected the VF triplet. Each triplet contained either baseline

MD or age matched VF from HTG, PACG, and NTG cohorts.
The computer program chooses a triplet when the MD
difference between groups was  0.1 dB or age difference
between groups was  to 11 months. If there were multiple
P Value

<0.001

combinations of matched triples, then we chose the triplet that

0.90

0.16

had least MD or age difference. The computer program

selected triplets with the condition that each patient’s VF data
was used only once.
3.7 (2.4 to 6.2) 3.7 (2.4 to 6.2) 3.7 (2.4 to 6.2)

0.4 (0.7 to 0.0)

Fast VF Progression. We defined fast VF progression as the

52 (44 to 61)

rate of worsening of MD greater than 1 dB/year with P value 

NTG

0.05. The P value for robust linear regression was obtained

Baseline MD Matched (N ¼ 76)

using Wald test for multiple coefficients of robust linear

regression. We chose this rate of progression (ROP) cut off
value because eyes with early glaucomatous VF damage
progressing at this rate will reach an end stage glaucoma in
Median (IQR)

10 to 15 years.23 We determined the fast progressing subtype

0.4 (0.8 to 0.0)

in a triplet by calculating the differences in the ROP between

50 (47 to 59)

eyes. In a triplet, if a particular subtype had a ROP greater than

PACG

1 dB/year compared to other two subtypes then that particular

subtype was labelled as fast progressing subtype in the triplet.
Figure 1 shows an example of a fast progressing subtype in
baseline MD matched triplet (Fig. 1A) and baseline age
matched triplet (Fig. 1B). In both of these triplets, the HTG
was a fast progressing subtype.
Rate of MD progression, in dB/y 0.5 (1.2 to 0.0)

Local VF Progression. For local VF progression, we

58 (50 to 65)

studied the (a) enlargement of scotoma, and (b) deepening of

HTG

scotoma in all the three glaucoma subtypes. We defined

scotoma enlargement as an appearance of new scotoma at last
visit, that is, VF locations that were normal at baseline visit but
showed pattern deviation probability (PDP) < 0.5% at last visit.
To estimate the scotoma deepening we used the point-wise
linear regression (PLR) technique. The PLR technique has been
described in detail elsewhere.36 Briefly, PLR fits a linear
regression to VF pattern deviation sensitivity values against
Parameters

the patient’s visit. In this study, we used robust linear

regression35 to calculate slopes and locations. They were
Baseline MD, dB

considered as significantly progressing when the slope was

Baseline age, y

greater than 1 dB/year and had a P value  0.01. For the

outermost points in 24-2 VF, slope greater than 2 dB/year with
P value  0.01 was used. The VF locations with significant PLR
progression were determined for scotoma deepening analysis.
For all local analysis, VF locations (X ¼ 15, Y ¼ 63 degrees)

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 Visual Field Progression in Subtypes of Glaucoma
FIGURE 2. VF was divided into three zones central, superior arcuate, and inferior arcuate. Locations marked with ‘‘X’’ were excluded from analysis.
above and below the blind spot were eliminated from the
analysis and VF locations with PDP < 0.5% at baseline were
excluded from the analysis.
VF defects were shown to have an impact on the vision-
related quality of life.26–32 Different areas/zones of VF loss
would have a different impact on the vision-related quality of
life. To estimate which VF zone was more prone to scotoma
enlargement and/or deepening in each subtype, we divided
VFs into three zones: central, superior arcuate, and inferior
arcuate (shown in Fig. 2).
Statistical Methods
A generalized estimate equation (GEE) was used to compare
the parameters between groups as we used data from both
eyes. A v2 test was used to compare the proportion of eyes
with a subtype of glaucoma that had fast progressing eye in the
triplet analysis. One-way ANOVA was used to calculate the
significant difference between zones and 2-way ANOVA was
used to find the interaction between zones and groups.
Statistical significance was set at P  0.05. All statistical
analysis was performed using ‘‘R’’ software.33
RESULTS
In total, 2065 patients had clinical diagnosis of glaucoma and
had five or more VFs between January 2000 to December
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IOVS j March 2019 j Vol. 60 j No. 4 j 892
2012. Among these, 213 HTG (310 eyes), 206 PACG (304 eyes),
and 108 NTG (165 eyes) were included in the study. The
remaining eyes were excluded and the reasons were unreliable
follow-up VFs or irregular follow-up (n ¼ 784), cataract or
glaucoma filtration surgery (n ¼ 111), other ocular diseases
such as age-related macular degeneration (ARMD) (n ¼ 285),
pseudoexfoliation (n ¼ 42), diabetic retinopathy (n ¼ 81
patients), hypertensive retinopathy (n ¼ 36), anterior ischemic
optic neuropathy (AION) (n ¼ 18), papilledema (n ¼ 14), optic
neuritis (n ¼ 8), and retinal vein occlusion (n ¼ 159), which
could affect the VFs.
Global VF Progression
Table 1 shows the median and interquartile range (IQR) of the
baseline age, baseline MD, and years of follow-up for HTG,
PACG, and NTG eyes.
Figure 3 shows the distribution of MD progression rate in
the three subtypes of glaucoma. The median progression rate
(in dB/year) and IQR in HTG was 0.3 (1 to 0), PACG was
0.3 (0.8 to 0), and NTG was 0.3 (0.7 to 0.1). The global
median progression rates between groups did not show a
statistically significant difference (P ¼ 0.44). However, the
proportion of eyes showing fast progression (MD worsening
greater than 1 dB/year) between groups showed a statistically
significant difference (v2 test: P ¼ 0.03). In our cohort, 45 out
of 310 eyes (14.5%) in HTG, 39 out of 204 eyes (12.8%) in
 Visual Field Progression in Subtypes of Glaucoma
FIGURE 3. Distribution of MD progression rate (dB/year) in HTG, PACG, and NTG. Global VF progression.
PACG, and 24 out of 165 eyes (14.5%) in NTG showed fast
progression.
A total of 76 triplets were matched based on their baseline
MD (severity matched) and 106 triplets were matched based
on their age at presentation. The baseline parameters of the
subtypes of glaucoma cohorts among these triplets matched
for MD and age are given in Table 2.
In 36 out of 76 baseline MD matched triplets, none of the
subtypes had ROP differences greater than 1 dB/year between
them. In the remaining 40 triplets, HTG had the greatest
proportion of progressing eyes (n ¼ 20 of 40 eyes; 50%),
followed by NTG (n ¼ 11 of 40 eyes; 28%), and PACG (n ¼ 9 out
of 40 eyes; 22%) (Fig. 4A). A v2 test showed a statistically
significant difference in the proportion of progressing eyes
between HTG and PACG (P ¼ 0.04). The differences between
HTG versus NTG and PACG versus NTG were not significant.
Similarly, in 58 out of 106 baseline age matched triplets,
none of the subtypes had ROP differences greater than 1 dB/
year between them. In the remaining 48 triplets, both HTG
eyes (n ¼ 17 out of 48 eyes; 35%) and NTG eyes (n ¼ 17 out of
48 eyes; 35%) had similar proportion of progressing eyes
followed by PACG (n ¼ 14 out of 29 eyes; 29%) (Fig. 4B). A v2
test showed no statistically significant difference in the number
of progressing eyes between the subtypes of glaucoma (Fig.
4B).
IOP is known to influence the VF progression.37,38 We
collected the IOP values of all eyes from triplet analysis. Figure
5 compares the baseline IOP (IOP value measured on first
visit), peak IOP (maximum recorded IOP during follow-up
visits), and follow-up IOP (average IOP values of all visits) for
the fast progressing eye in triplets versus other two eyes in the
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triplet. The mean follow-up IOP was higher (P ¼ 0.001) in the
fast progressing eye in MD matched and in the age matched
triplet (P ¼ 0.04) compared to the other two eyes in the triplet.
The baseline IOP and maximum IOP were not statistically
significantly different between the fast progressing eye and
other two eyes in the triplet.
In the triplet analyses, we defined fast progressing subtype
as the difference in the rate of MD progression greater than 1
dB/year compared with other subtypes. To check the
robustness of our results, we repeated analyses with different
rates of progression (ROP) cut off values. Figure 6 shows the
number of progressing eyes for each subtype with different
ROP cut off values for both MD and age matched triplets. A
similar trend was noted with HTG showing a greater number
of eyes progressing compared to NTG and PACG at all five
different ROP cut offs.
Local VF Progression
In moderate and advanced glaucoma, VF locations might have
already reached the floor effect at P < 0.5%. Because these
defects are so deep, they are unlikely to change and if they do
so, they tend to be unreliable.39 Therefore, for local VF
progression analysis we included only early glaucoma, that is,
MD equal to or better than 6 dB at baseline. In total 406 eyes
were included. Out of which, 135 eyes in HTG, 183 eyes in
PACG, and 88 eyes in NTG had MD equal or better than 6 dB
at baseline. The median (IQR) of the baseline MD for the three
subgroups were HTG: 3.17 (2.23, 4.13) dB, PACG: 2.65
(1.38, 4.02) dB, and NTG: 3.34 (1.99, 4.33) dB (P ¼
0.81). The number of VF visits between groups was not
 Visual Field Progression in Subtypes of Glaucoma
FIGURE 4. Number of eyes that showed MD progression rate greater than 1 dB/year among the triplets. (A) Number of progressing eyes in each
subtype with baseline MD matched triplet. (B) Number of progressing eyes in each subtype with baseline age matched triplet.
statistically significant (P ¼ 0.65) and the mean number of VF
visits in PLR analysis was 7 in each subtype. However,
approximately 27.4% (37 eyes) in HTG, 23.4% (43 eyes) in
PACG, and 44.3% (39 eyes) in NTG had VF with only five visits.
Figure 7 shows (A) baseline threshold values, (B) percent-
age of eyes showing scotoma enlargement at each VF location,
and (C) percentage of eyes showing scotoma deepening at
each VF location in HTG, PACG, and NTG. The dB values and
percentages were pseudo-color coded according to the color
bar shown in Figure 7.
Figure 8A shows the percentage of eyes with scotoma
enlargement in the three different zones among the glaucoma
subtypes. Each dot in the box plot represents one VF location
in the corresponding zone. One-way ANOVA showed signifi-
cant difference between zones in all three subtypes: HTG F(2,
29) ¼ 4.87, P ¼ 0.015; PACG: F(2, 29) ¼ 5.387, P ¼ 0.01; and
NTG F(2, 29) ¼ 22.05, P < 0.001. Post-hoc analysis using Tukey
HSD test revealed greater scotoma enlargement in the superior
arcuate zone in HTG and NTG and inferior arcuate zone in
PACG. Two-way ANOVA showed significant difference, F(4, 87)
¼ 7.937, P < 0.001, suggesting scotoma enlargement zone
were not similar between the glaucoma subtypes.
Figure 8B shows the percentage of eyes with scotoma
deepening at superior arcuate, inferior arcuate, and central
zones in three subtypes of glaucoma. Each dot in the box plot
represents one VF location in the corresponding zone. One-
way ANOVA showed significant difference between zones in all
three subtypes: HTG F(2, 29) ¼ 11.69, P < 0.001; PACG: F(2,
29) ¼ 7.46, P ¼ 0.002; and NTG: F(2, 29) ¼ 4.93, P ¼ 0.014.
Post-hoc analysis using Tukey HSD test showed superior
arcuate zone in POAG and NTG and inferior arcuate zone in
PACG with greater scotoma deepening. Two-way ANOVA
showed a significant difference F(4, 87) ¼ 6.039, P < 0.001,
suggesting scotoma deepening zone were not similar between
subtypes.
Figure 9 shows the progression rate in each zone for all
three subtypes (dots in the boxplot represents the progression
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rate for each VF location in that zone). As seen only in NTG,
the progression rates were significantly different between
zones. Two-way ANOVA showed significant interaction be-
tween zones and subtype: F(4, 87) ¼ 6.23, P < 0.001.
DISCUSSION
This study aimed to assess VF progression in the three subtypes
of primary glaucoma—in HTG, PACG, and NTG subjects under
clinical care of glaucoma specialists. The median VF progres-
sion rate found in this study is similar to the VF progression
rates reported in clinical trials, which ranged from 0.0 dB/year
to 1.1 dB/year.3,6,8–10
The median ROP among all three subtypes was similar (0.3
dB/year). The mean progression rates in the study by De
Moraes et al.19 for HTG, PACG, and NTG were 0.48 dB/year,
0.39 dB/year, and 0.33 dB/year, respectively. Majority of
HTG (53.9%), PACG (54.3%), and NTG (63%) eyes had slope
value between 0 and 1. Approximately, 22.3% of eyes in HTG,
28.3% of eyes in PACG, and 20% of eyes in NTG had slope value
greater than zero. Similar positive slope values in VFs have
been reported in major randomized controlled trials (RCTs)
and clinic-based studies.3,6,8–10 The positive slopes are
attributed to the learning effect, measurement variability,40,41
and true improvement beyond the measurement variability
related to clinical parameters.42
For global VF progression, we matched VFs based on
baseline severity and age. The result as shown in Figure 4A
suggests that even though all three subtypes of glaucoma had
the same level of disease severity at baseline, HTG subtype had
greater proportion of eyes progressing compared to NTG and
PACG. However, when subtypes were matched based on age at
presentation (Fig. 4B), all three subtypes had a similar
proportion of progressing eyes.
Various studies have reported that PACG eyes to be at
two times higher risk of blindness compared to the
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FIGURE 5. Baseline IOP, peak IOP, and follow-up IOP for fast progressing eye and other two eyes in the triplets.

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 Visual Field Progression in Subtypes of Glaucoma
FIGURE 6. Number of eyes that showed progression in the three glaucoma subtypes at different rates of progression cut off values. (A) Baseline MD
matched triplet and (B) baseline age matched triplet.
POAG.13,14,16,17,43,44 This was also noted in the Andhra Pradesh
Eye Disease Study (APEDS), which reported 20% bilateral
blindness in PACG compared to 11% in POAG.45,46 However, in
the current clinic based study, we noted lower progression
rates in PACG compared to HTG when baseline severity was
matched. The reason for this discrepancy could be due to the
study type and the level of clinical care. Studies that concluded
higher risk of blindness in PACG eyes were cross-sectional
population-based prevalence studies,13,14,16,17,43,44 whereas
the current study is a clinic-based study.
The level of clinical care available for patients in population-
based estimate studies cannot be commented on. In our study,
patients were under the clinical care of glaucoma specialist and
had a regular follow-up. The possible reasons for the higher
risk of blindness in PACG in population-based studies may be
due to lack of awareness of the disease, poor access to health
care, disease diagnosis at advanced stages, and including
patients with acute angle closure attack. In our study, we
excluded patients with a history of acute angle closure attack.
In our study, all eyes in the PACG group had LPI as primary
procedure in the management and later treated with appro-
priate medical treatment. This study suggests that diligent
clinical care of PACG eyes, which includes an LPI as initial
treatment and standard treatment thereafter, can lower VF
progression rates in PACG.
Clinical parameters such as pseudoexfoliation, poor IOP
control, number of glaucoma medications, and surgical
interventions are known to affect the rate of VF progres-
sion.3,6,37,38,47,48 In our study, we excluded all eyes with
pseudoexfoliation and eyes that underwent surgical interven-
tion. When we compared the IOP between the fast progressing
eye and the other two eyes in the triplet (both age and MD
matched), the median follow-up IOP was higher in the fast
progressing eye compared to the other two eyes in the triplet.
This suggests that the difference in the progression rates
between subtypes could be due to higher mean follow-up
IOPs.
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Learning effect is shown to influence VF progression.40,41
To rule out the suspicion of learning effect influencing our VF
progression between groups, we compared the slope of the
first three VFs between groups. The median slope (IQR) for
first three VFs in HTG, PACG, and NTG were 0.2 (0.5 : 1.1),
0.2 (0.6 : 1), and 0.1 (0.5 : 0.9), respectively (P ¼ 0.918).
This suggests that the learning effect between groups was not
different and hence may not have influenced the VF
progression rate between groups.
It is well-known that VFs in glaucomatous eyes progress in
one or a combination of the following: new defects,
deepening, or expansion of an existing defect. The findings
in our study were consistent with it. HTG and NTG showed
scotoma enlargement and deepening in superior arcuate zone,
whereas PACG showed scotoma enlargement and deepening in
inferior arcuate zone. Although, in HTG and PACG, the number
of locations that show progression (both enlargement and
deepening) were different, the rate at which these zones
progress, that is, the average dB loss per year for each zone
were not significantly different between zones in HTG and
PACG (Fig. 9).
Our study agrees with previous studies that the nasal region
and the superior arcuate region is the most common location
for VF defects in HTG.21,22,24,49 Similarly, the paracentral region
and VF locations close to fixation are more prone to VF defects
in NTG. An interesting finding in our study was that in PACG
the inferior arcuate locations were more prone to scotoma
enlargement compared to superior arcuate locations.
Cross-sectional studies comparing the total deviation values
of the superior hemifield with that of the inferior hemifield at
various stages (mild, moderate, and severe) of PACG reported
greater total deviation values in the superior than in the
inferior hemifield.25,50 Verma et al.51 have shown that in early
PACG, greater number of locations progressed in superior
temporal Garway-Heath (GH) VF sector compared to inferior
temporal GH VF sector. The reason for this discrepancy
between Verma et al.51 and our study results may be due to the
difference in the criteria for progression used in these studies.
 Visual Field Progression in Subtypes of Glaucoma
FIGURE 7. (A) Baseline threshold values in dB; (B) percentage of eyes showing scotoma enlargement at each VF location; (C) percentage of eyes
showing scotoma deepening at each VF location. The dB values and percentages are pseudo color coded according to the color scale shown in the
right. Each column corresponds to one subtype of glaucoma.
We defined significant pointwise VF progression as slope was
greater than 1 dB/year with P < 0.01 and for edge/peripheral
locations slope greater than 2 dB/year with P < 0.01.
However, in their study, the rapid progression was defined as
slope < 1.5 with no criterion set on P value.
Most studies divide VF into GH VF sectors.52 We choose to
divide VF into three zones: central, superior arcuate, and
inferior arcuate because of the functional implications of VF
defects in these zones and on vision-related quality of life.26–29
We ran the same analysis dividing into GH VF sectors (results
not shown) and the conclusion remained the same; the
superior temporal sector in HTG and NTG and inferior
temporal GH sector in PACG showed greater scotoma
enlargement and deepening.
Various studies have shown patients with superior VF
defects have difficulty in driving and reading task,27–29,31
whereas patients with inferior VF defects have difficulty in
mobility and increased rates of falls.26,27,53 In our study, HTG
and NTG showed significant scotoma deepening in superior
arcuate zone, whereas in PACG the inferior zone showed
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IOVS j March 2019 j Vol. 60 j No. 4 j 897
significant scotoma deepening. Therefore, the vision related
quality of life would be differently affected in the PACG group
compared to HTG and NTG groups.
Our study has its limitations, many confounders that would
influence the disease progression such as between visit IOPs,
compliance to medications, regularity of follow-up, and
persistence to treatment cannot be commented on since these
data were not evaluated. Also, because of the retrospective
nature of this study, the effects of systemic and hemodynamic
factors on progression have not been looked at. Other factors
could be that in the baseline MD matched cohort, the HTG
cohort was on average 4 years older compared to PACG;
therefore, the increase in age and the effect of possible
cataractous changes on MD cannot be ruled out.
We used MD to calculate global VF progression. The MD
was calculated using total deviation values, which were shown
to be affected by media opacities.54–56 Since cataract grading
data were not available in our retrospective data, the effect of
cataract in our data set cannot be commented. We made an
assumption that the cataract effect on MD in all three subtypes
 Visual Field Progression in Subtypes of Glaucoma IOVS j March 2019 j Vol. 60 j No. 4 j 898

FIGURE 8. Boxplot showing the percentage of eyes showing scotoma enlargement (A) and scotoma deepening (B) at superior arcuate (SA), inferior
arcuate (IA), and central zones in the three glaucoma subtypes. Each dot in the boxplot represents one VF location in the corresponding zone. An
asterisk indicates the group responsible for significance in the post-hoc analysis.

would be similar because the age group in three subtypes were
similar. The VF index (VFI)57 calculated from PDP plots could
have been less prone to cataract changes. However, we
avoided using VFI because at both early and late stages of
glaucoma VFI can be unreliable. Rao et al.58,59 have shown that
when MD crosses 20 dB the decrease in VFI can be highly
variable. Artes et al.60 have shown that in early glaucoma when
MD was better than 5 dB, the ceiling effect on VFI would
influence progression analysis.
Years of follow-up and time between follow-up was shown
to influence the MD regression analysis.61 To detect a change
of 1 dB/year for a moderately variable VF with a power of 80%
requires 9 years of follow-up period.61 Although the median
follow-up period was greater than 9 years in this study, the
frequency of VF testing was longer 1.6 years (Table 1). A
limitation of PLR analysis in our study was few of the VF in PLR
analysis have only five visits. The PLR analysis have poor
specificity for VF with only five visits (series). Since a greater
proportion of eyes in NTG had lesser VF visits compared to the
other two groups, the specificity of PLR analysis in NTG maybe
poorer compared to HTG and PACG. Hence, PLR analysis in
NTG should be interpreted with caution while comparing with
other subtypes.
Another limitation of our study was that all patients in our
study underwent SITA test strategy that uses a ‘‘growth
pattern’’ to estimate the VF defects. Briefly, growth pattern

FIGURE 9. Boxplot showing the ROP (dB/year) at superior arcuate (SA), inferior arcuate (IA), and central zones in the three subtypes of glaucoma.
An asterisk indicates the group responsible for significance in the post-hoc analysis.

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 Visual Field Progression in Subtypes of Glaucoma
estimates threshold at four fixed primary locations (in case of
SITA they are 12.78 from fixation in each quadrant) and the
starting intensity for the secondary location is borrowed from
the primary location.62 Studies have shown that the defect at
the primary location will have an effect on secondary
locations,63 a false or incorrect response at the primary
location may give rise to a false increase in the spread of VF
defects. This type of artefact arises when the patient was not
attentive or learning to do the test in the first few minutes of
testing. Since primary locations were tested first, an incorrect
response at these locations may result in a false spread of VF
defects. Finally, the 68 grid used by the 24-2 SITA program may
not be adequate to pick up subtle scotoma,64 as a result, the
spatial spread of progression measured using a 68 grid may be
undersampled.
In this study, we have shown that the global rates of VF
progression were less in PACG than HTG when the baseline
severity were matched, and the pattern of progression for
PACG was different from HTG. Several studies have shown that
the pattern of structural damage is also different between HTG
and PACG,24,64,65 which may suggest different disease mech-
anism and pathology for PACG compared to HTG.21–24
In conclusion, in patients under clinical care by glaucoma
specialists, VF progressed faster in HTG compared to PACG and
NTG.
Acknowledgments
The authors thank Amina Jaleel and Yerkala Arun Kumar for
helping with data collection.
Disclosure: S. Ballae Ganeshrao, None; S. Senthil, None; N.
Choudhari, None; S. Sri Durgam, None; C.S. Garudadri, None
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