Visual Fields in the OCT Era - Dr. Graham Lakkis

Discussion in 'CEwire2018' started by AdminWolf, Jan 20, 2018.

  1. AdminWolf

    AdminWolf Site Administrator & Tech Lead
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    Visual Fields in the OCT Era: Dr. Graham Lakkis (55861-GL)




    Watch the entire presentation & earn COPE credit at CEwire2018!
     
  2. Charles A McBride

    Charles A McBride ODwire.org Supporting Member

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    Such an outstanding lecture! The last summary slide is amazing.

    Question: If one follows the Crabb protocol based on the UKGTS of three VFs at diagnosis followed by three VF's at the two year mark, and determines the patient has a "non-catastrophic" rate of field progression, how often would you recommend one has his/her patients perform fields going forward?
    -Charlie

    Charles McBride, O.D.
    Beaverton, OR
     
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  3. #3 Jan 21, 2018
    Last edited: Jan 21, 2018
    Graham Lakkis

    Graham Lakkis ODwire.org Supporting Member

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    Hello Charlie,

    Glad you found the presentation interesting. I hold the regular participants here on OD Wire in high esteem regarding their optometric knowledge, and was a little worried you already “knew it all” and would find the lecture too basic.
     
  4. Graham Lakkis

    Graham Lakkis ODwire.org Supporting Member

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    It depends on the size of the error bars in the calculations of progression rate made by the perimeter.

    For example if the progression rate is -1.00dB/year +/- 2 dB then the true rate could be anywhere from +1 to -3 dB/ yr. I would keep testing frequently until I had greater confidence in the result. If it was -1 +/- 0.1 dB/year I would be happy to just do an annual VF.

    The whole purpose of this information is to get us to do a really quick 24-2 Sita fast/er VF frequently rather than a 30-2 Sita Standard VF once every year or two.
     
  5. Michael R. Young O.D.

    Michael R. Young O.D. ODwire.org Supporting Member

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    Excellent lecture on Visual Fields and Glaucoma. Should be required viewing for anyone treating Glaucoma.

    I will be changing my protocol for VF use based on this lecture.

    My only concern is whether the patient's insurance will be willing to pay for VF testing 3 months in a row.

    I hate working for free and the patients always think their insurance should pay for testing instead of them.
     
  6. Steve Silberberg

    Steve Silberberg ODwire.org Supporting Member

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    Yes Graham: WE are changing are protocols based on the research as to when do fields. The one problem: Will Medicare and insurances pay for 3 baseline fields
     
  7. Graham Lakkis

    Graham Lakkis ODwire.org Supporting Member

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    Everybody, don't get too hung up about what Medicare allows. Insurance/Government often lags behind best practice till it become standard of care.

    Remember, the purpose of "clustering" VF tests close to each other (rather than evenly spacing them every 6 to 12 months) is that the disease process would not have progressed at all in the 4 weeks between VF's, so any variability is due to the patient's responses, not disease progression. Therefore the perimetry software can get a much more valid statistical significant determination of true disease progression in a much shorter time by comparing the average VFI/MD in each cluster with that performed 1, 2 and 3 years later where glaucoma could have worsened.

    If the patient will not pay the small fee out-of-pocket, then it would be reasonable to perform VF's at Months 0 and 1, 12 and 13, 24 and 25. This will still give you 6 clustered VF's in 2 years so you can more accurately and rapidly determine progression rate.
     
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  8. Joe DiGiorgio O.D.

    Joe DiGiorgio O.D. ODwire.org Supporting Member

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    Very Nicely done Graham

    I made a summary of most of the slides in your presentation. With the permission of @Graham Lakkis and @AdminWolf, I will be happy to post it on this thread.
     
  9. Joe DiGiorgio O.D.

    Joe DiGiorgio O.D. ODwire.org Supporting Member

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    I am curious to ask others: I tried 24-2 SITA Fast, but it seemed it was quite fast/rushed for many patients so we switched back to SITA STD. Can any others comment of your successes with SITA-Fast? Perhaps I need to rethink my protocol. Taking a VF test is dreadful and any way we can increase the patient alertness and accuracy is noble.
     
  10. Laurence Craig Thomas

    Laurence Craig Thomas Well-Known Member

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    Another example of science being ahead of guidelines, rules and regulations.

    I find it interesting to see the initial acceptance of everything Dr. Lakkis had to say, but alternatively, I sometimes find resistance among the ODwire membership when similar statements are made about clinical information in other domains.

    Dr. Lakkis, great lecture.
     
  11. Jonathan Warner

    Jonathan Warner ODwire.org Supporting Member

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    Sounds like this will be a great lecture when I get to it.

    Are we able to print pages off these presentations?
     
  12. Graham Lakkis

    Graham Lakkis ODwire.org Supporting Member

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    Joe,

    I believe that SITA Fast has smaller brightness steps between presentations when thresholding a point in space compared to SITA Standard which is what makes it quicker. Otherwise the timing of the stimuli is the same.

    I use SITA Fast all the time and patients are universally happy with it. Much shorter test times.
     
  13. Joe DiGiorgio O.D.

    Joe DiGiorgio O.D. ODwire.org Supporting Member

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    I will need to go back and try it again. We sometimes do fields on each other on Wednesdays. Probably not tomorrow as we are pretty booked. I thought the timing was quicker and the patient seemed more rushed on SITA Fast. Will be taking another look.

    May I post my notes?
     
  14. Charles A McBride

    Charles A McBride ODwire.org Supporting Member

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    When SITA Fast was first introduced I recall hearing that the stimuli were presented faster depending on the response time. Would be curious to know if this is true. I'll try and test it tomorrow.
     
  15. Graham Lakkis

    Graham Lakkis ODwire.org Supporting Member

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    There should never be blind acceptance of any scientific theory, including those I presented, which are not my work but those of respected colleagues.

    In fact Andrew Anderson who is an OD/PhD at our institution doesn’t necessarily agree this is the best approach:

    Detecting glaucomatous progression with infrequent visual field testing.
    Anderson AJ, et al. Ophthalmic Physiol Opt. 2018.
    Show full citation
    Abstract
    PURPOSE: Previous work has investigated whether a significant regression slope in the first 2 years for the summary index Mean Deviation (MD) is predictive of rapid (≤-2 dB/year) glaucomatous visual field progression. This work assumed six visual fields were obtained as per management guidelines, but in clinical practice commonly only two or three fields are measured.

    METHODS: We simulated visual field series (N = 100 000) spaced annually in the first 2 years and then biennially. We calculated positive and negative predictive values (PPV & NPV).

    RESULTS: Prediction values at 2 years were slightly less than those obtained using six visual fields. An addition of an appropriate slope based criterion materially improved PPV, with little detrimental effect.

    CONCLUSION: Infrequent visual field testing does not dramatically alter predictive values at 2 years, but does substantially delay when significant progression may first be detected.

    © 2018 The Authors Ophthalmic & Physiological Optics © 2018 The College of Optometrists.
     
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  16. Allan Panzer

    Allan Panzer ODwire.org Supporting Member

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    As usual I have a couple of questions...

    I see you are on line.

    I understand the three tests initially, what I cannot determine is why on earth...you would wait two years for additional testing?

    Especially if they are rapid..makes zero sense to me.

    Second..I realize you glanced over the Octopus instrument.

    I have utilized it for many years..got my first VF in 1983..hmmm
    Next one in 1994. Octopus 123
    Does 24-2 in less than two minutes.

    Does 10-2 in less than two minutes.

    HFA just has better PR...not necessarily a better instrument.

    I feel this at the least needs to be mentioned..

    Not glanced over in thirty seconds.

    Excellent presentation..
    Just my two cents.
     
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  17. Graham Lakkis

    Graham Lakkis ODwire.org Supporting Member

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    Hello Allan, yes I'm online responding to your comments on the LASIK/glaucoma thread!

    1. You need between about 2 years (in a good test taker) and 4 years (in a poor test taker) for the VFI/MD to change more than the natural variability of the visual field testing process. If you look at the table from Chauhan in my lecture, you can see that the detection time is quicker when the rate of deterioration is greater, which makes sense as the change in MD/VFI will be much greater than normal fluctuation.

    Dave Crabb in his paper on this theory even mentions that if you simply can't wait the two years, it is OK do another VF at month 12, but it doesn't really speed up your calculation of the progression rate. In fact having equally spaced fields over the course of 2 years makes it harder to differentiate test variability from disease progression and increases your chance of false positives.

    2. No disrespect to the Octopus perimeter. I didn't have much to say because I have never seen one here in Australia or know of anyone using one either. Same as the Heidelberg edge perimeter, never seen one. It was mentioned because, like the Medmont, I believed it tested more central points than the HFA without having to run separate macular VF.

    In Australia, Medmont and Humphrey have the market stitched up, with the occasional Oculus EasyField and Matrix
     
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  18. Joe DiGiorgio O.D.

    Joe DiGiorgio O.D. ODwire.org Supporting Member

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    I felt you had all your key points well referenced by highly credentially authors.
     
  19. Allan Panzer

    Allan Panzer ODwire.org Supporting Member

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    I met Chauhan when I went to BC back in 1994...an amazingly smart guy. It was interesting.all these heavy weights in Glaucoma and there was this guy...from a strip center in Texas..almost laughable.

    The father and son Sampaolisi or however you spell that kept asking me..so who are you? And "why" are you here?

    But I digress..i think the common sense question is..if a person is a rapid changer and you wait two years, surely you miss something.

    I think what you really miss is the opportunity to emphasize that there may be a problem.

    Every time I turn around 18 months have gone by instead of twelve.

    The Sampaolisis' actually checked IOP every hour for 15 hours a day. They got to their offices at 7:00 and left late in the night.

    I'm not an academian..but its sometimes fun to hang out with some really smart people.

    So, when I bought the HRT in 1994 from John Hawley..hmmmmm an Aussie..now with Optovue....he got me the invite.

    Cause I was stinking crazy to spend $53K back then on unproven technology.
     
  20. Joe DiGiorgio O.D.

    Joe DiGiorgio O.D. ODwire.org Supporting Member

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    Allan what is your typical protocol for frequency of VF testing?
     
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