Advancing glaucoma progression detection: Simulated evaluation of 24-2 and 10-2 visual field testing strategies using real-world data

To evaluate whether alternating 24-2 and 10-2 visual field (VF) testing improves overall glaucoma progression detection compared with 24-2 or 10-2 alone, and to determine whether this enhances detection within the macular region, using simulated series derived from real-world data. Retrospective, observational simulation study Retrospective VF data from 426 eyes were used for simulations Pointwise slopes were estimated from 24-2 and 10-2 VFs using hierarchical modelling with location-level random intercepts/slopes. Eye-specific residuals formed noise templates. These were combined with estimated slopes to simulate 426 dense VF series (every 3-months), representing stable (slope=0) and progressing eyes. Four strategies were created and tested over 24-months: (A) simultaneous 24-2 and 10-2 at every visit, (B) 24-2 alone, (C) 10-2 alone and (D) alternating 24-2 and 10-2. Progression was determined using hierarchical modeling and strategy detection (hit) rate was assessed via cluster-adjusted ROC analyses, reporting sensitivity at 95% specificity and partial AUCs. At 12-months, sensitivity at 95% specificity was 79%, 67%, 67% and 63% (A–D); corresponding partial AUCs were 0.033 (A) and 0.025 (B–D). A had a significantly higher AUC than B, C, and D at 12-months (p<0.001 each). B exceeded C at 12 months (p=0.015), while D and B did not differ (p=0.570) and D exceeded C (p=0.016). By 24-months, sensitivities converged for A and B (87% each), with 79% (C) and 80% (D). Similar results were seen in 244 eyes defined as early-stage glaucoma at baseline. For 284 eyes defined as macular progressors at 12-months, B detected 80% and D 81% of eyes identified by 10-2. Alternating 24-2 and 10-2 testing provided no clear benefit over 24-2 alone, which remained robust for progression detection. Simultaneous testing is optimal but not clinically practical.