Lacrivera

Visual Fields in the OCT Era - Dr. Graham Lakkis

Allan Panzer said:
The difference is that unlike most of you, I try to get all of my OHT patients SLT.

That way I can watch with a bit more comfort. BTW...there are studies that state that Hysteresis demonstrates who will best benefit from drops...or SLT..can't remember and I'm not that good at quickly finding those suckers...but I remember seeing one recently.

And in another ten years maybe..everyone will realize the benefit of SLT for compliance..

And just maybe you'll say..

Damn, that Panzer guy was doing that ten years plus ago..
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Joe DiGiorgio O.D. said:
Graham

Thanks for all the great input and guidance.

So to review the STD/Fast/Faster protocol:

Do you baseline your suspects with SITA Std? then at some point do you transition to "Fast"

Thank you again.
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Joe,

The HFA-3 is set up with 24-2 SITA Fast as the default and that is what we use for baseline and all follow-ups.

Remember, both SITA Std and SITA Fast give up a little in precision to gain a lot in patient reliability, without significantly affecting our ability to detect progression of glaucoma.
 
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Angel Adolfo Camblor said:
I believe Dr. Farkas stated you can sign up as a student, but you will not be subjected to a test at the end (so no credit). It's free that way and I don't believe he minds or he would not have put that info out there. So kudos to OdWire for sharing the knowledge.

I paid for mine,.... only because I need the CE hours. :D

Also many thanks to Dr. Panzer for sharing, truly! Net positive, reading your posts, but I think Lloyd is correct. Tad bit grumpy to friend Troy.

Time to get me some protein;).
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CEwire2018 is happy to allow free access to ODs who did not need state board credit. The mechanics of test taking and state board credit have expenses attached, so there is no choice but to charge when credit required..

You have to wonder if by government mandate the need for C/E credits for relicensure were eliminated, what would happen to optometric continuing education?
 
I've been running the SITA Faster for the past two weeks. (Maybe 6 patients) Very impressed so far. All were previous patients and I'd say average test time was a little over two minutes per eye. Patients loved it.

My main concern was if this is a test that can be done to establish a baseline or only for follow-up visits to look for progression. According to Grahams lecture, it can be a baseline test.

Thanks for a very informative CE class..... I may just watch it again.
 
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Jeff Summers said:
I've been running the SITA Faster for the past two weeks. (Maybe 6 patients) Very impressed so far. All were previous patients and I'd say average test time was a little over two minutes per eye. Patients loved it.

My main concern was if this is a test that can be done to establish a baseline or only for follow-up visits to look for progression. According to Grahams lecture, it can be a baseline test.

Thanks for a very informative CE class..... I may just watch it again.
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Jeff what was your prior protocol?
 
I have been using sita fast since it first came out. Patients constantly complained about the 6 minute per eye test time.

So far most patients sit back after the sita faster test and say "hey. That wasnt so bad today. What changed?"
 
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The Octopus 123 has been doing full thresholds in less than two minutes for what...30 years.
Got mine in 1994 when I bought the HRT.

Thought it would be good if and when I ever published(which I did not) to say the same company.

VSI apparently sells them.

Newer versions are still way way less than HVFA.

https://patternless.com/product/octopus-123-visual-field/
 
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When we entered the management of glaucoma we did not have a huge knowledge pool or experience base. My primary experience was running Goldman perimetry at Chicago's West Side VA under Tom Stelmack OD.

We modeled much of our contemporary care on the OHTS study and the teachings and text book by Murray Fingeret, OD. I am almost Certain that Murray preferred HVF 24-2 SITA -Std.

Some are faster, some are slower, but we tried to follow this protocol. It is also the same workup used by our glaucoma fellows down at Rush Pres under the guidance of Steven Brown MD and Madhu Gorla MD, who are top guns and optometric friendly.
 
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Paul Farkas said:
CEwire2018 is happy to allow free access to ODs who did not need state board credit. The mechanics of test taking and state board credit have expenses attached, so there is no choice but to charge when credit required..

You have to wonder if by government mandate the need for C/E credits for relicensure were eliminated, what would happen to optometric continuing education?
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Interesting question. It would probably become mostly corporate sponsored expositions to pitch products. A lot of that already takes place. Even worse for participation would be if tax write-offs for travel and expenses were dis-allowed.
 
The Humphrey Field Analyzer is archaic and ghastly. The Zeiss H.F.A.-3 came around more than a decade too late after the -II (or the -IIi), and offered virtually nothing but the omission of a thermal printer, and the loss of a touch-screen that pre-dated the Nintendo 64. All this said, history binds most of us to this instrument, and we simply cannot discard years of patient-data in favor of migrating to the Octopus 900 (or to any other competitor).

With respect to perimetry itself, of course it maintains its stature in the care of multitudinous eye-diseases, certainly comprising glaucoma. As with O.C.T.s, high-quality baseline studies are requisite, and this means, to me, in many circumstances, striving to obtain at least three tests over a year or so. As with anything, case-specific details, patient criteria, and clinic-pragmatism teeter one closer to this point, else farther away in either direction.
 
With respect to the H.F.A.'s S.I.T.A.-Standard versus -Fast strategies, the latter works about as well, and consumes only roughly two-thirds the time. Rarely, therefore, do I initially elect for the -Standard protocol, reserving this (for the sake of consistency) typically for those cases in which a patient has substantial history of taking said test.
 
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Rahul M. Gupta said:
With respect to the H.F.A.'s S.I.T.A.-Standard versus -Fast strategies, the latter works about as well, and consumes only roughly two-thirds the time. Rarely, therefore, do I initially elect for the -Standard protocol, reserving this (for the sake of consistency) typically for those cases in which a patient has substantial history of taking said test.
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Thanks for sharing your experience Rahul. So it sounds like you are evaluating most suspects with 24-2 SITA Fast, and also following suspects and diagnosed glaucoma patients with said test. It that correct?

Many thanks.
 
Joe DiGiorgio O.D. said:
Thanks for sharing your experience Rahul. So it sounds like you are evaluating most suspects with 24-2 SITA Fast, and also following suspects and diagnosed glaucoma patients with said test. It that correct?

Many thanks.
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Overall, in glaucoma-care, yes, I generally use the 24-2 S.I.T.A.-Fast protocol. This said, depending on the case, as well as on whether I seek additional information, I shall use the 30-2 S.I.T.A.-Fast; and, in several instances, I shall incorporate 10-2 S.I.T.A.-Fast tests.
 
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Angel Adolfo Camblor said:
Interesting question. It would probably become mostly corporate sponsored expositions to pitch products. A lot of that already takes place. Even worse for participation would be if tax write-offs for travel and expenses were dis-allowed.
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am I missing something?

Perhaps you could hit the quote button so this would make sense. I'm sure you area answering something stated somewhere.
 
Rahul M. Gupta said:
All this said, history binds most of us to this instrument, and we simply cannot discard years of patient-data in favor of migrating to the Octopus 900 (or to any other competitor).
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4572983/

And my history binds me to the 123.

But for what it is worth...its so much faster than the HFA..

I can't even imagine 5+ minutes when mine takes less than 2.

The 10-2 uses 80 points and takes less than two minutes.
 
Allan Panzer said:
am I missing something?

Perhaps you could hit the quote button so this would make sense. I'm sure you area answering something stated somewhere.
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I was answering Paul's question on post 41, about the elimination of CE requirements.
 
Allan Panzer said:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4572983/

And my history binds me to the 123.

But for what it is worth...its so much faster than the HFA..

I can't even imagine 5+ minutes when mine takes less than 2.

The 10-2 uses 80 points and takes less than two minutes.
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Except the results are not as good.

http://iovs.arvojournals.org/article.aspx?articleid=2163285
"conclusions. The TOP procedure has a number of unusual spatial characteristics that prevent it from accurately estimating the spatial extent and absolute sensitivity of visual field defects."

I believe it is said that fast is not better.
 
Lloyd Pate said:
Except the results are not as good.

http://iovs.arvojournals.org/article.aspx?articleid=2163285
"conclusions. The TOP procedure has a number of unusual spatial characteristics that prevent it from accurately estimating the spatial extent and absolute sensitivity of visual field defects."

I believe it is said that fast is not better.
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Hi Lloyd. I believe I recall you stating there was another ARVO reference that discussed repeatability of the STD vs the Fast. So the test -retest repeatability was the point in question. Do you possibly still have that reference?

Many thanks.
 
Joe DiGiorgio O.D. said:
Hi Lloyd. I believe I recall you stating there was another ARVO reference that discussed repeatability of the STD vs the Fast. So the test -retest repeatability was the point in question. Do you possibly still have that reference?

Many thanks.
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Here is one. There are others, so I don't know if it is the right one.

http://iovs.arvojournals.org/article.aspx?articleid=2124008

conclusions. SITA Standard may be superior to the Full Threshold strategy for monitoring patients with visual field loss. The greater test–retest variability of SITA Fast in areas of low sensitivity is likely to offset the benefit of even shorter test durations with this strategy. The sensitivity differences between the SITA and Full Threshold strategies may relate to factors other than reduced fatigue. They are, however, small in comparison to the test–retest variability.
 
I am lucky to be friends with co-workers who do research in visual fields and glaucoma. One is doing research with monkeys. He has them trained to do visual fields. For research, they can not do Sita Std or fast because of the variability in the results. The fewer passes across the threshold leaves a greater margin of error. This margin of error is large enough to hide significant changes in the fields for research. That is way everyone at the university compromises and does SITA std.
 
Dr. Lakkis, there were days of past where assistants would push the start button and leave patients in a box to complete the 24-2. Is it possible that for tests run like that the three in a row is more important than for a field test that is carefully monitored by experienced administrators of the test? The answer must be yes, but I wonder if it is enough to overcome the need for three initial tests as opposed to two. -Charlie
 
Charles A McBride said:
Dr. Lakkis, there were days of past where assistants would push the start button and leave patients in a box to complete the 24-2. Is it possible that for tests run like that the three in a row is more important than for a field test that is carefully monitored by experienced administrators of the test? The answer must be yes, but I wonder if it is enough to overcome the need for three initial tests as opposed to two. -Charlie
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From the World Glaucoma Association Consensus report.

https://wga.one/wga/consensus-8/

Section 1 – Visual function progression
  1. Standard white-on-white automated perimetry (SAP), with a fixed testing matrix covering at least the central 24 degrees, is preferred for measuring progression in eyes with glaucomatous VF loss.
    Comment: more research is needed into the use of alternative measures of visual function (FDP, resolution perimetry, motion perimetry and others) to detect glaucomatous progression, before any of these can be considered alternatives to SAP for measuring progression.
    Comment: It is possible for glaucomatous optic neuropathy to progress structurally in the absence of functional progression and vice-versa.
  2. Perform sufficient examinations to detect change.
    Comment: decisions on progression should not be made by comparing only the most recent field with the one before.
    Comment: suspected progression should be confirmed by repeating the field.
Baseline data collection (no previous VFs available) – first two years

  1. In clinical practice, at least two reliable VFs is optimal in the first six months.
    Comment: In clinical scenarios, where the lifetime risk of visual disability is high, such as those who already have advanced damage, three baseline VFs may be necessary.
    Comment: A good baseline of reliable VFs is essential to be able to monitor for progression.
    Comment: Unless there are obvious learning effects, high false-positive errors, rim artifacts, or other obvious artifacts, examinations should not be removed from the analyses.
  2. At least two further VFs should be performed within the next 18 months.
  3. VF testing should be repeated sooner than scheduled if possible progression is identified on the basis of an ‘event’ analysis.
    Comment: In patients at risk of visual disability, performing six VFs in the first two years enables the clinician to rule out rapid progression (2 dB/year or worse) and establishes an ideal set of baseline data.
    Comment: the identification of possible progression may be on the basis of an ‘event’ criterion such as the Glaucoma Progression Analysis (in the Humphrey perimeter software) or ‘Nonparametric Progression Analysis’.
  4. Establish a new baseline after a significant therapeutic intervention (e.g., surgery). Comment: the new baseline can be the last fields that defined the previous progression ‘event’.
Follow-up data collection (after the initial two years)

  1. The frequency of follow-up VFs should be based on the risk of clinically significant progression (based on extent of damage and life expectancy).
  2. In low and moderate risk patients, subsequent VF frequency should be one VF per year (unless there is a long follow-up) and, as a rule, repeated sooner if possible. Progression is identified on the basis of an ‘event’ analysis, or if other clinical observations are suggestive of possible progression or increased risk of progression.
    Comment: relevant clinical observations include structural progression (clinically noted or measured by imaging), a splinter hemorrhage, or inadequate IOP control.
  3. In high risk patients, subsequent VF frequency should be two VFs per year and repeated sooner if possible progression is identified on the basis of an ‘event’ analysis, or if other clinical observations are suggestive of progression or increased risk of progression.
    Comment: following confirmed progression (by an ‘event’), the frequency of testing should be based on the estimated rate of progression, risk factors and other clinical indicators of progression, stage of disease and life expectancy.
    Comment: patients who have been stable for a long period, or who are progressing so slowly as to be at little risk for reaching disabling levels of field loss, and other clinical parameters indicate low risk of progression, may have VF testing less frequently than 1 VF per year.

Also:
https://wga.one/wga/consensus-10/

  1. Standard white-on-white automated perimetry (SAP), with a fixed testing matrix covering at least the central 24 degrees, is preferred for the diagnosis of glaucomatous visual field loss.
    Comments: Goldmann size III stimuli are conventionally used in most automated perimeters in clinical practice for glaucoma diagnosis. For more severe cases size V, increases the dynamic range and reduces variability of test results. Using the 10-2 strategy, in addition to the conventional 24-2 Humphrey grid, can improve the detection of central functional loss
  2. Threshold algorithms are preferred over supra-threshold algorithms for glaucoma diagnosis.
    Comment: Supra-threshold algorithms can be helpful in cases of unreliable results from threshold testing algorithms.
  3. Neither short-wavelength automated perimetry (SWAP) nor frequency doubling technology (FDT) perimetry have superior diagnostic precision to SAP.
 
Interesting references Lloyd. I see that Weinreb has has John Hancock on the editor's list. He, Quigley, and Tsai are a few of the lead glaucoma fellows that have participated at the annual UIC glaucoma conference.
 
Lloyd Pate said:
Threshold algorithms are preferred over supra-threshold algorithms for glaucoma diagnosis.
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So fast or faster strategies have wider brackets that make a precise threshold less precise. It appears they feel it is a clinically significant issue.

Also it sounds like for patients that have reduced reliability the faster strategy may be worthwhile. Quick and dirty is better than higher fixation losses or false pos and false neg results.
 
Joe DiGiorgio O.D. said:
So fast or faster strategies have wider brackets that make a precise threshold less precise. It appears they feel it is a clinically significant issue.

Also it sounds like for patients that have reduced reliability the faster strategy may be worthwhile. Quick and dirty is better than higher fixation losses or false pos and false neg results.
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I reserve fast for patients with physical problems that make taking longer fields a problem like palsies and bad necks or backs.
 
Charles A McBride said:
Dr. Lakkis, there were days of past where assistants would push the start button and leave patients in a box to complete the 24-2. Is it possible that for tests run like that the three in a row is more important than for a field test that is carefully monitored by experienced administrators of the test? The answer must be yes, but I wonder if it is enough to overcome the need for three initial tests as opposed to two. -Charlie
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No, it's the clustering of the tests close together that allows the patient's variability to be determined, and the increased number of tests in the first 2-4 years that allows the rapid determination of trend analysis/progression rate. Remember the slide in my presentation where 2 baselines and another VF every 6 mths gives 6 tests in 2years but did not perform as well as the 3 clustered tests at the beginning and of the 2 year period.

Monitoring the patient closely during the test does help reliability (allows you a re-align positioning, remind the patient to fixate) and reduces unreliable tests, but would not speed up determination of the progression rate per se. The studies I quoted all assume reliable VF's in the analysis (but different amounts of threshold variability), and in real life testing, the progression analysis software will usually omit tests with excessive false positives and fixation losses from its progression analysis anyway. i.e. monitoring the patient may get you more reliable VF's but won't alter the spacing/timing of the VF's required to determine progression rate.
 
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I wish that sitting in a perimeter bowl was more engaging sort of like playing a virtual reality high tech video game.

I recently sat at the perimeter to perform a kinetic field test. I know what I am supposed to do, yet it is so darn boring and so easy to look away from the fixation point.
 
I encourage everyone to check out the awesome presentation that Graham did on CEwire. Thank you again Graham for being the catalyst behind this interesting discussion (my wife disagrees, but at least my daughter is on board :) )
 
Joe DiGiorgio O.D. said:
I wish that sitting in a perimeter bowl was more engaging sort of like playing a virtual reality high tech video game.

I recently sat at the perimeter to perform a kinetic field test. I know what I am supposed to do, yet it is so darn boring and so easy to look away from the fixation point.
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Our students have to give patients feedback while they are taking the test. It helps to know you are making progress and doing it right and when you are 1/4, 1/2 and 3/4 of the way through the test. A bag of popcorn or glass of Tang after the test works too.

I really have given patients cups of coffee before the test. Some now ask for it.
 
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Joe DiGiorgio O.D. said:
So fast or faster strategies have wider brackets that make a precise threshold less precise. It appears they feel it is a clinically significant issue.

Also it sounds like for patients that have reduced reliability the faster strategy may be worthwhile. Quick and dirty is better than higher fixation losses or false pos and false neg results.
Click to expand...

The most precise determination of the threshold for a particular point in the visual field is with the Full Threshold strategy which was the only thresholding option in the original perimeters. But full threshold takes forever (15 min per eye) so SITA Standard and SITA Fast were developed using presumption on what the threshold should be based on the patient's hill of vision in adjacent points to those already measured, and a smaller number of steps in the thresholding process. Lloyd posted a reference earlier in this thread that compared the three different strategies, and yes, both SITA's are slightly poorer than the full threshold, but not dramatically so, and with the benefit of improved reliability indices.

Where SITA Fast performs the worst is in advanced VF loss (low sensitivities) where it inherently difficult to precisely and repeatably measure the threshold of the points. So if you wanted to maximise accuracy, you could switch to SITA standard or Full Threshold in those with advanced glaucoma (MD worse than -12dB). But in the types of patients OD's typically see (suspects and early glaucoma), SITA Fast is really just as good as SITA Standard, and does not reduce the detection of glaucoma significantly, or reduce the ability to determination the progression rate.

I do not know anyone that performs full thresholds in clinic, and I don't believe we use it any of our clinical research here at the university of Melbourne. It just takes way too long.

P.S. I feel there may have been a misunderstanding of nomenclature: "Suprethreshold" is the term for points presented at (usually) 3dB brighter that then presumed hill of vision, to only record whether they are seen or not (what we could call a "screening" strategy). "Threshold" refers to Full threshold, SITA Standard, SITA Fast and SITA Faster where an actual sensitivity figure is determined for each point in space. In glaucoma we should always use one of the Threshold strategies, but can use a screening strategy only as a last resort if a patient simply can't perform any of the threshold tests.
 
Graham Lakkis said:
I do not know anyone that performs full thresholds in clinic, and I don't believe we use it any of our clinical research here at the university of Melbourne. It just takes way too long.
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We are required to use full threshold on humans and monkeys both.

The monkeys actually love doing visual fields. They want that glass of Tang at the end of a good job.
 
Graham Lakkis said:
But in the types of patients OD's typically see (suspects and early glaucoma), SITA Fast is really just as good as SITA Standard, and does not reduce the detection of glaucoma significantly, or reduce the ability to determination the progression rate.
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That is a pretty true statement. There is just a debate here whether the difference is significant. Research here shows that it is. That is why we must use standard threshold tests in research and choose to run Sita STD on patients.
 
Graham,

I want to take the time to say I appreciate your presentation and replies. They are very educated and cordial. I mean no disrespect to you. My friends at the university and I always discuss topics like this because we know the "truth" is always changing and we have to change with it. I am always looking to see where I am wrong and welcome help seeing that.

Lloyd
 
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This discussion is amazing.

Can you imagine a Rip Van Winkle waking up after 20 years sleep, to observe this conversation between Australia ,Texas, Illiniois and Oregon occurring in real time?

Thank you all.
 
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For those who haven't seen Dr. Lakkis' talk, i've posted an excerpt in the first post of this thread.

I'm doing the same thing with a bunch of other CEwire2018 lectures, hopefully it'll stimulate discussion & get people motivated to visit the conference

thanks!
adam
 
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Graham Lakkis said:
The most precise determination of the threshold for a particular point in the visual field is with the Full Threshold strategy which was the only thresholding option in the original perimeters. But full threshold takes forever (15 min per eye) so SITA Standard and SITA Fast were developed using presumption on what the threshold should be based on the patient's hill of vision in adjacent points to those already measured, and a smaller number of steps in the thresholding process. Lloyd posted a reference earlier in this thread that compared the three different strategies, and yes, both SITA's are slightly poorer than the full threshold, but not dramatically so, and with the benefit of improved reliability indices.

Where SITA Fast performs the worst is in advanced VF loss (low sensitivities) where it inherently difficult to precisely and repeatably measure the threshold of the points. So if you wanted to maximise accuracy, you could switch to SITA standard or Full Threshold in those with advanced glaucoma (MD worse than -12dB). But in the types of patients OD's typically see (suspects and early glaucoma), SITA Fast is really just as good as SITA Standard, and does not reduce the detection of glaucoma significantly, or reduce the ability to determination the progression rate.

I do not know anyone that performs full thresholds in clinic, and I don't believe we use it any of our clinical research here at the university of Melbourne. It just takes way too long.

P.S. I feel there may have been a misunderstanding of nomenclature: "Suprethreshold" is the term for points presented at (usually) 3dB brighter that then presumed hill of vision, to only record whether they are seen or not (what we could call a "screening" strategy). "Threshold" refers to Full threshold, SITA Standard, SITA Fast and SITA Faster where an actual sensitivity figure is determined for each point in space. In glaucoma we should always use one of the Threshold strategies, but can use a screening strategy only as a last resort if a patient simply can't perform any of the threshold tests.
Click to expand...

Myself, I do not switch from the S.I.T.A.-Fast to the -Standard strategy simply because disease is advanced. In my experience, neither test, clinically, is superior to the other, and the -Fast takes substantially less time, which behooves both the patient and the practice.

Another caveat remains, the S.I.T.A.-Fast and the -Standard are not interchangeable in the H.F.A.'s Glaucoma Progression Analysis (G.P.A.) program, which is extremely helpful in tracking pathology (remarkably, the Full Threshold and the -Standard or the -Fast, are). I do, at some point, switch from the 24-2 or 30-2 (and, yes, I shall employ the latter in various cases) to the 10-2 (S.I.T.A.-Fast), and might perform the former with a Size-V target; or, I might take advantage of kinetic perimetry.

There does, of course, exist a point at which perimetry no longer yields useful data, and one simply must track I.O.P., listen to symptoms, and work with a patient toward the latter's blindness.
 
Rahul M. Gupta said:
Myself, I do not switch from the S.I.T.A.-Fast to the -Standard strategy simply because disease is advanced. In my experience, neither test, clinically, is superior to the other, and the -Fast takes substantially less time, which behooves both the patient and the practice.

Another caveat remains, the S.I.T.A.-Fast and the -Standard are not interchangeable in the H.F.A.'s Glaucoma Progression Analysis (G.P.A.) program, which is extremely helpful in tracking pathology (remarkably, the Full Threshold and the -Standard or the -Fast, are). I do, at some point, switch from the 24-2 or 30-2 (and, yes, I shall employ the latter in various cases) to the 10-2 (S.I.T.A.-Fast), and might perform the former with a Size-V target; or, I might take advantage of kinetic perimetry.

There does, of course, exist a point at which perimetry no longer yields useful data, and one simply must track I.O.P., listen to symptoms, and work with a patient toward the latter's blindness.
Click to expand...

Rahul, we are in agreement. I have been using 24-2 SITA Fast as my default strategy since purchasing the HFA3 in 2015. It works really well in practice.

As mentioned previously, it appears that the new software upgrade to introduce SITA Faster to the HFA3 will now allow progression analysis of SITA STD/FAST/FASTER. Looking forward to receiving the upgrade soon.
 
Graham Lakkis said:
Rahul, we are in agreement. I have been using 24-2 SITA Fast as my default strategy since purchasing the HFA3 in 2015. It works really well in practice.

As mentioned previously, it appears that the new software upgrade to introduce SITA Faster to the HFA3 will now allow progression analysis of SITA STD/FAST/FASTER. Looking forward to receiving the upgrade soon.
Click to expand...

I, too, have been awaiting us to install the new software on our machine. Thus far, I've understood the only change with the 24-2 S.I.T.A.-Faster protocol is the introduction of two central points (taking the total count from fifty-four to fifty-six), though I admit to being else unfamiliar (and, even in the mentioned regard, I am uncertain).
 
Rahul M. Gupta said:
Myself, I do not switch from the S.I.T.A.-Fast to the -Standard strategy simply because disease is advanced. In my experience, neither test, clinically, is superior to the other, and the -Fast takes substantially less time, which behooves both the patient and the practice.

Another caveat remains, the S.I.T.A.-Fast and the -Standard are not interchangeable in the H.F.A.'s Glaucoma Progression Analysis (G.P.A.) program, which is extremely helpful in tracking pathology (remarkably, the Full Threshold and the -Standard or the -Fast, are). I do, at some point, switch from the 24-2 or 30-2 (and, yes, I shall employ the latter in various cases) to the 10-2 (S.I.T.A.-Fast), and might perform the former with a Size-V target; or, I might take advantage of kinetic perimetry.

There does, of course, exist a point at which perimetry no longer yields useful data, and one simply must track I.O.P., listen to symptoms, and work with a patient toward the latter's blindness.
Click to expand...


The other day I had a patient come in with what I thought were obviously two blind eyes. Oh my heavens. I thought about photographing it but it might actually make you a bit ill.

Anyhow, she came in and had a pair of +10 glasses. she could actually see out of the Opaque eye. The other eye was sort of rolled up and out..

Combigan, Xalatan, Azopt...

All she wanted was a new script for the drops.

Now, I have a lot of IOP gadgets, but none that can measure a micro cornea that is opaque.

It looked like she had one of those plastic implants, but alas, it was just her eye. Looked like a tiny blue ring where her cornea should have been. Instead it was about a 5mm white cornea.

I'm not buying a diaton or whatever that gadget is called for one patient.

Anyone else treat a glaucomatous kid..she's like 19...without the benefit of any sort of IOP.

Oh my..why on earth did she pick me?
 
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