Increased reliance on newer ocular imaging technologies may undermine patient care

Over the past decade, ophthalmologists and optometrists have turned to a range of newer technologies — beyond visual field testing and straightforward fundus photography — to evaluate patients with and suspected of having open-angle glaucoma.

 Joshua Stein, M.D., M.S.

But a new study published in Ophthalmology, January 2012, reports that increased reliance on these newer technologies as a replacement for the more traditional visual field testing and fundus photography may undermine patient care.  The investigation focused on trends in eye care provider use of three methods for evaluating patients with open-angle glaucoma or suspected glaucoma: visual field testing, fundus photography, and other ocular imaging technologies.

Among these newer imaging technologies, the three most commonly relied upon approaches are confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (SLP), and optical coherence tomography (OCT) — all of which evaluate the optic nerve or retinal nerve fiber layer tissue, the structures in the back of the eye which can be damaged by glaucoma.

The findings, reported by Joshua D. Stein, M.D., M.S., a glaucoma specialist at the University of Michigan W.K. Kellogg Eye Center, and his colleagues emerged from a study of claims data of 169,917 individuals with open-angle glaucoma and 395,721 individuals suspected of having glaucoma aged 40 years and older enrolled in a national managed care network between 2001 and 2009. 

“Over the past decade, we found a substantial increase in the use of newer ocular imaging devices and a dramatic decrease in the use of visual field testing in the management of patients with and suspected of having open-angle glaucoma by ophthalmologists and optometrists,” says Dr. Stein.  “Our results indicate that the odds of a patient undergoing visual field testing decreased by 36% from 2001 to 2005, by 12% from 2005 to 2009, and by 44% from 2001 to 2009. By comparison, the odds of undergoing testing using the newer ocular imaging devices increased by 100% from 2001 to 2005, by 24% from 2005 to 2009, and by 147% from 2001 to 2009.”

Dr. Stein notes that, “Until these newer imaging devices can be demonstrated to identify the presence of open-angle glaucoma and capture disease progression as well as more traditional methods do, providers should use these devices as an adjunct to — not a replacement for — visual field testing and fundus photography.” Such findings suggest that greater efforts need to be made to educate eye care providers about the importance of visual field testing in glaucoma management.

Several factors likely contribute to the recent shift to newer technologies.  The newer imaging procedures are painless, can be performed quickly, require little patient cooperation, do not rely on subjective patient input, and often can be obtained without dilation of the patient’s pupils.  By comparison, visual field testing takes longer to perform, requires more patient effort, and is largely subjective.

Financial incentives may also drive use of these newer technologies. Since the imaging devices are expensive to purchase, the more tests eye care providers order, the quicker they can recoup equipment costs and eventually generate revenue.

A major cause of permanent but preventable vision loss, glaucoma affects 2.2 million Americans. January is National Glaucoma Awareness Month.  Dr. Stein and his colleagues emphasize the importance of early detection, ongoing monitoring, and treatment to prevent vision loss from glaucoma.


Trends in use of ancillary glaucoma tests for patients with open-angle glaucoma from 2001 to 2009. Ophthalmology, 2012 Jan 3. [Epub ahead of print]


Joshua D. Stein, M.D., M.S., Nidhi Talwar, M.A., Alejandra M. LaVerne, B.S., Bin Nan, Ph.D., Paul R. Lichter, M.D.

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