Expert panel assesses visual function tests for use in diabetic retinal disease staging
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Key takeaways:
- Best corrected visual acuity was the only visual function test ready for use in a diabetic retinal disease staging system.
- Some visual function tests showed potential for screening and research purposes.
Although best corrected visual acuity was the only visual function test ready for immediate use in a diabetic retinal disease staging system, others showed promise or potential, according to a report published in Ophthalmology Science.
“BCVA is the primary method of visual function assessment both in clinical practice and in clinical research for diabetic retinal disease,” Adam R. Glassman, MS, executive director of the Jaeb Center for Health Research in Tampa, Florida, and colleagues wrote. “Given that many patients with diabetic retinopathy have visual disturbances that may not be fully reflected by BCVA, additional measures of visual function should be considered in care.
“Furthermore, BCVA is affected late in the disease process and is not affected in early disease,” they added.
As part of the Mary Tyler Moore Vision Initiative’s diabetic retinal disease staging system update, Glassman and colleagues formed a working group to evaluate the relationship between diabetic retinal disease and visual function parameters and determine their potential predictive and prognostic ability.
The working group met weekly for 3 months and ultimately determined that seven visual function tests of primary interest had sufficient preliminary data to suggest an association with diabetic retinal disease and therefore warranted further review: microperimetry, static automated perimetry, electroretinogram (ERG) oscillatory potentials, flicker ERG, low luminance visual acuity (LLVA), contrast sensitivity and BCVA. After subsequent online and in-person workshops, the working group added objective field analysis as a visual function test of interest.
The working group used evidence grids to determine which visual function tests were ready (< 2 years), promising (2 to 5 years) or had potential (> 5 years) for use in a diabetic retinal disease staging system.
Overall, BCVA was the only visual function test ready for immediate use, although only in mid- and late-stage clinical disease, according to the experts.
Contrast sensitivity, LLVA and flicker ERG were promising in both early- and mid-stage clinical disease. Objective field analysis was also promising, specifically in preclinical disease, and had potential for use in early and mid-stage clinical disease.
Additionally, the researchers found that LLVA, contrast sensitivity, flicker ERG and objective field analysis had potential for screening and research purposes, along with BCVA.
“Although BCVA is important, its utility is primarily in mid- to later-stage disease,” the experts wrote. “Other visual function measurements have the potential to help monitor early disease and predict progression to more advanced disease. However, large longitudinal studies are needed to evaluate their benefit.”
Glassman and colleagues noted that one limitation of their report was the fact that it was not a formal systematic review.
“However, the multistep evaluation approach by multiple experts should have helped identify any gaps in the review,” they wrote.
Perspective
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Crystal Maharrey, OD, MPH, FAAO
BCVA is the most common visual parameter monitored in diabetic retinal disease; however, patients may experience other visual disturbances in milder stages of disease, in which BCVA is preserved. This article investigates whether other visual sequelae can be used to improve staging of diabetic retinal disease, especially in earlier disease.
Of the seven visual parameters selected, BCVA was found to rank highest in monitoring, predictive and prognostic metrics, though it may underestimate impact of peripheral diabetic eye disease and early diabetic eye disease. Other parameters ranking high in these categories include contrast sensitivity and flicker ERG.
While this article proposes a more sensitive approach in evaluating diabetic retinal disease, most clinicians would find the suggested parameters difficult to incorporate in clinical practice, since the testing procedures and equipment are not standard in most practices. Additionally, changes in these parameters alone are not likely to alter clinical decisions regarding treatment as long-term data regarding clinical outcomes are needed.
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Glassman AR, et al. Ophthalmol Sci. 2024;doi:10.1016/j.xops.2024.100519.
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