HFA II-i with Guided Progression Analysis (GPA) Sample cases

// CONFIDENCE MADE BY CARL ZEISS

Part I GPA Summary Report 3

Part II Understanding GPA Reports 4

Part III GPA Sample Cases

Case 1 Slow progression 6

Case 2 Resetting the baseline 7

Case 3 Excluding a non-representative exam 8

Case 4 Life expectancy considerations 9

Case 5 Cataract patient 10

Case 6 Insufficient exams 11

Table of Contents

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Part I. GPA Summary Report

The diagnosis and management of glaucoma critically relies on assessment of visual field status and progression. Now you

can estimate the stage of visual field loss and its rate of progression, and assess your patient’s risk of future vision loss –

all at a glance. The Humphrey® Field Analyzer II-i (HFA™ II-i) with Guided Progression Analysis™ (GPA™) software delivers

current exam results, trends the overall visual field history and projects future vision loss all on a single page. The GPA

Summary Report presentation format is designed to simplify and streamline clinical interpretation.

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Baseline Exams Establish initial visual field status.

VFI Value A summary measurement of the patient’s visual field status, expressed as a percent of a normal age-adjusted visual field.

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VFI Rate of Progression Analysis Trend analysis of the patient’s overall visual field history.

VFI Plot Regression analysis of VFI values and 3 to 5 year projection.

VFI Bar A graphical depiction of the patient’s remaining useful vision at the current VFI value along with a 3 to 5 year projection of the VFI regression line if the current trend continues.

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Current Visual Field Summary Complete report of current visual field including VFI, MD, PSD, the Progression Analysis Plot and the GPA alert.

GPA Alert A message that indicates whether statistically significant deterioration was noted in consecutive tests.

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Pioneered by Boel Bengtsson, PhD1

as a more intuitive assessment of

visual function, VFI is optimized for

progression analysis. VFI is center-

weighted to correlate with ganglion

cell density and visual function. It is less

affected by cataract and other media

changes compared with earlier indices.

On the GPA Summary Report, VFI is

used to quantify rate of progression,

where it is plotted relative to patient

age to calculate the rate of functional

loss. This brochure provides an overview

of the GPA software for the HFA II-i and

some real life case examples showing

how VFI is used in GPA.

The GPA Summary Report is a powerful

one-page report that provides an

overview of the patient’s entire visual

field history. The report can be divided

into three sections: the Baseline exams

at the top, the visual field history and

trend in the middle, and the current

exam at the bottom. Elements of each

section are described below.

GPA Baseline Exams

At the top of the report are the two

Baseline Exams. Graytone and Pattern

Deviation Plots are shown for both GPA

Part II. Understanding the GPA Summary Report

1 Bengtsson B, Heijl A. A visual field index for calculation of glaucoma rate of progression. Am J Ophthalmol, 2008 Feb; 145(2): 343-53.

Baselines, along with key indices such

as VFI, MD, and PSD. By default, the

oldest two exams of the same type are

automatically selected as Baseline. Then

the initial selection of a SITA Standard

or a SITA Fast Exam determines which

exams will be included as follow-up

exams. It is critical that you ensure

that tests included in the Baseline are

representative of the patient’s actual

Baseline status. SITA Standard and SITA

Fast Exams cannot be combined in

the GPA analysis. Also, GPA supports

Central 30-2 and 24-2 tests in the same

analysis, but when combined, GPA will

analyze all tests as if they were 24-2

tests. GPA does not support FastPac

tests or Central 10-2 tests for either

Baseline or Follow-up.

VFI Plot

In the center of the report, the VFI

Plot graphs the VFI values of all exams

included in the GPA analysis as a

function of the patient’s age. The VFI

Plot also provides a linear regression

analysis of the VFI over time when

appropriate. A minimum of 5 exams

over 3 years or more must be included

in GPA for the linear regression results

to be presented.

Note: The regression line slope may be positive due to statistical uncertainty or the Learning Effect.

VFI Plot VFI Bar

GPA uses the Visual Field Index™ (VFI™), a

summary measurement of a patient’s visual field

status expressed as a percent of a normal age-

adjusted visual field.

5Deviation from Baseline Plot

Three Possible GPA Alerts:1. "Likely Progression"2. "Possible Progression"3. "No Progression Detected"

Progression Analysis Plot

VFI Bar

To the right of the VFI Plot is the VFI

Bar that indicates the patient’s current

VFI value. In addition, when the results

of the regression analysis are displayed,

the VFI Bar will also graphically indicate

the 3 to 5 year projection of the linear

regression line, shown as a broken line.

The length of projection is equal to the

number of years of GPA data that is

available, up to a maximum projection

time of 5 years.

Deviation from Baseline Plot

The deviation from Baseline Plot

compares the pattern deviation of

the most recent Follow-up test to

the average of the pattern deviation

values of the two Baseline tests, and

indicates changes at each tested point,

in dB notation.

Progression Analysis

Probability Plot

The Progression Analysis Probability Plot

gives the statistical significance of the

dB changes shown in the deviation from

Baseline Plot. It compares the changes

between the Baseline and Follow-up

exams to the inter-test variability typical

of stable glaucoma patients2 and then

shows a plot of point locations, which

have changed significantly.

Points that have changed by more

than the expected variability are

identified with a simple and intuitive

set of symbols:

A single, solid dot indicates a

point not changing by a significant

amount.

A small open triangle identifies

a degree of deterioration expected

less than 5% of the time at that

location in stable glaucoma

patients (p < 0.05).

A half-filled triangle indicates

significant deterioration at that

point in two consecutive tests.

A solid triangle indicates

significant deterioration at that

point in three consecutive tests.

An X signifies that the data at that

point was out of range for analysis.

For data that is out of range, GPA

cannot determine whether or not the

encountered deviation at that point

is significant. This occurs mainly with

field defects that were already quite

deep at Baseline.

GPA Alert

The GPA Alert is a message in plain

language terms that indicates whether

the GPA progression criteria were met.

The GPA Alert assists you in recognizing

deterioration in consecutive tests. In

cases where three or more points show

deterioration in at least two consecutive

tests, the progression analysis indicates

“Possible Progression.” In cases where

three or more points show deterioration

in at least three consecutive tests,

the progression analysis indicates

“Likely Progression.” When neither of

the foregoing conditions applies, a

message of “No Progression Detected”

is displayed.

2 Arnalich-Montiel F, Casas-Llera P, Muñoz-Negrete FJ, Rebolleda G. Performance of glaucoma progression analysis software in a glaucoma population. Graefes Arch Clin Exp Ophthalmol, 2009 Mar; 247(3): 391-7. Epub 2008 Nov. 4.

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Part III. Sample Case 1 Slow progression

Slow progression may not necessarily be vision threatening

This is an example of a patient with slowly progressing visual field loss. The event analysis (GPA Alert)

indicates “Likely Progression”. However, the VFI slope is nearly flat and the confidence intervals are narrow.

This patient’s visual field loss is measurably progressing (based on the change probability map) but only very

slowly, and the patient may not be at significant risk of visual impairment during his lifetime.

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Patient is 74 years old.

VFI slope is nearly flat and the

confidence intervals are narrow.

Event analysis (GPA Alert)

indicates “Likely Progression”.

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Updating baseline after significant treatment change

The first four exams showed fast progressing visual field loss, followed by a change in treatment.

Post-treatment exams are severely depressed, and it is not clear whether the patient’s visual field stabilized

after the fourth exam.

Part III. Sample Case 2 Resetting the baseline

By re-establishing baseline after a

significant therapeutic change, it

is easier to see that the patient’s

visual field has somewhat stabilized.

The GPA analysis now displays a

shallower VFI progression line,

along with the label “Slope not

significant”. While this patient’s

vision is already so damaged that

further increases in therapy may

still be needed, this analysis gives a

more complete picture for assessing

risks vs. possible benefits.

First four exams showed fast

glaucoma progression,followed

by change in treatment.

Has the patient’s visual field

stabilized after the fourth exam?

Severely depressed visual field

on latest exam.

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Before: with default baseline selections

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After: with adjusted baselines

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Excluding non-representative exams

Notice that the third exam on this report has a markedly worse VFI. In this case the patient probably was just

having a bad day, because the next visit shows a much improved field, more like the first and second exams.

In a case like this, it is important to deselect that particular exam and not use it in the GPA.

Part III. Sample Case 3 Excluding a non-representative exam

Before: with poor exam included

The third exam on this

report has a markedly

worse VFI.

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2 Notice that the VFI regression

line in the “After” example with

the poor exam deselected is a

much more typical looking

regression line than in the

“Before” example.

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1After: with poor exam excluded

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Part III. Sample Case 4 Life expectancy considerations

Life expectancy can be an important consideration

A progression rate that might be acceptable at age 90 may not be acceptable at age 65.

3 Event analysis (GPA Alert)

indicates “Likely Progression”.

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Age at most recent exam is 65.

VFI progression is

-3.0 ± 0.9% per year.

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VFI reduces the effect of cataract 3,4

This is an example of an eye with concomitant glaucoma and cataract where the MD values reflect

much more loss than the VFI. The time of cataract surgery is marked by the red arrow in both graphs.

Part III. Sample Case 5 Cataract patient

3 Bengtsson B, Heijl A. A visual field index for calculation of glaucoma rate of progression. Am J Ophthalmol, 2008 Feb; 145(2): 343-53.

4 Leung CK, Cheung CY, Weinreb RN, Qiu K, Liu S, Li H, Xu G, Fan N, Pang CP, Tse KK, Lam DS. Evaluation of retinal nerve fiber layer progression in glaucoma: a study on optical coherence tomography guided progression analysis. Invest Ophthalmol Vis Sci, 2010 Jan; 51(1): 217-22. Epub 2009 Aug 13.

Old GPA

MD follow-up (dB/year)

VFI follow-up from same patient

Cataract Surgery

Cataract Surgery

New GPA1 After surgery, MD levels

approach those seen in

the baseline exams.

2 Here is the same series

of fields with Guided

Progression Analysis.

As opposed to MD,

VFI is hardly influenced

by cataract and the

corrected rate of

progression is almost

zero. This patient has

stable glaucoma and it is

much easier to see this

with the VFI plot.

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Part III. Sample Case 6 Insufficient exams

A patient with only one exam

When there are insufficient exams to perform a GPA analysis, the default report is the Single Field

Analysis (SFA) Report. Single Field Analysis remains the standard until follow-up is established.

VFI is calculated along with MD

and PSD for each reliable exam.

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