Comparison of Structural, Functional, Tonometric, and Visual Acuity Testing for Glaucoma: A Prospective Diagnostic Accuracy Study

Purpose: To determine the diagnostic accuracy of potential screening tests for moderate to advanced glaucoma. Design: Prospective diagnostic test accuracy study. Participants: The study enrolled a consecutive series of patients aged ≥50 years who presented to a glaucoma clinic in South India without ever having received automated visual field testing. Methods: All participants underwent 8 index tests: OCT of the peripapillary retinal nerve fiber layer, optic disc photography, Moorfield's Motion Displacement Test (MDT), frequency doubling technique perimetry, noncontact tonometry, pneumatonometry, presenting visual acuity, and best-corrected visual acuity. Participants also underwent stereoscopic photographs and Humphrey visual fields, which were used by 2 ophthalmologists to arrive at the reference standard diagnosis of moderate to advanced glaucoma. Main Outcome Measures: Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. Results: A total of 217 people were enrolled; 321 eyes from 180 participants had all tests performed. Of these, 127 eyes (40%) were classified as having moderate to advanced glaucoma. Among the 8 tests, OCT best optimized sensitivity (84%, 95% confidence interval [CI], 76–90) and specificity (75%, 95% CI, 68–81). Moorfield's Motion Displacement Test was the best perimetric test, with a sensitivity of 91% (95% CI, 85–96) and specificity of 53% (95% CI, 44–61). Pressure and vision tests were not sensitive (e.g., sensitivity of 16%, 95% CI, 9–23 for noncontact tonometry and 23%, 95% CI, 15–31 for best-corrected visual acuity). Moorfield's Motion Displacement Test identified 16 of 127 eyes (13%) with glaucoma that were not captured by OCT, but also had false-positive results in 65 of 194 eyes (34%) without glaucoma that OCT correctly classified as negative. Conclusions: OCT had moderate sensitivity and fair specificity for diagnosing moderate to advanced glaucoma and should be prioritized during an initial assessment for glaucoma.