AAOph Says Visual Electrophysiology Isn’t Ready for Routine Use to Diagnose Glaucoma

A recent position paper from the American Academy of Ophthalmology indicates that the current evidence supports visual electrophysiology as a promising adjunct in glaucoma care, but not as a routine frontline diagnostic test. Photo: Kim H, et al. Ophthalmic Res. March 8, 2025. Click image to enlarge. Standard automated perimetry remains the main functional test for glaucoma, but it is subjective and depends heavily on patient cooperation, fixation and reliable responses. Because of its variability, and since a substantial proportion of retinal ganglion cells may already be lost before visual field defects are detected, there is interest in more objective methods to assess visual function. One such approach is visual electrophysiology, which provides objective measurements of retinal and visual pathway function and may detect glaucomatous damage before standard visual field abnormalities appear. A team of investigators with the American Academy of Ophthalmology recently performed an Ophthalmic Technology Assessment to evaluate the current evidence on whether visual electrophysiology can help diagnose glaucoma and to determine its potential role in routine clinical practice. The review found that these tests, including electroretinography (ERG) and visual evoked potentials (VEP), can discriminate glaucomatous from control eyes and may be especially useful in select situations, such as preperimetric disease, uncertain structure-function relationships or patients unable to perform reliable perimetry; however, due to technical challenges, inconsistent protocols and a lack of standardized reference ranges, the AAOph concluded that visual electrophysiology is not yet recommended for clinical practice.To conduct the review, investigators searched PubMed for studies published between 2011 and 2025. The search yielded 738 articles, of which 20 met the inclusion criteria. These studies included adults 18 years and older with primary open-angle glaucoma (POAG) or open-angle glaucoma, a control group, at least 25 glaucoma eyes and analyses that accounted for inter-eye correlation.Among the modalities reviewed, photopic negative response (PhNR) and pattern electroretinography (PERG) showed the strongest diagnostic performance. PhNR amplitude distinguished early POAG from controls with an area under the curve (AUC) of 0.92 in one study, and focal ERG improved early glaucoma detection with AUCs of 0.82 to 0.92. PERG also performed well in early disease, with transient PERG P50 amplitude reaching an AUC of 0.93 for early POAG vs. controls and N95 amplitude reaching 0.78 in preperimetric glaucoma with RNFL defects.VEP findings were more mixed. Isolated-check VEP showed AUCs from 0.77 to 0.89, while multifocal VEP reached 0.91 in one study but was less consistent in others.Overall, the AAOph report states that while these tests have advanced over the years and show promise for detecting retinal ganglion cell dysfunction, especially in early glaucoma, none have enough standardization or evidence to support routine clinical use.“None of the visual electrophysiology tests have reached the level of evidence to achieve the standard set by perimetry for the detection of glaucoma,” the team wrote. Moreover, they highlighted several barriers to widespread clinical implementation, “including test-retest variability, requirements for equipment and skilled technicians, the lack of consensus stimulus and analysis protocols for glaucoma diagnosis, as well as standardized reference ranges.” Future research may help standardize testing protocols, improve reliability and clarify which patients are most likely to benefit from these objective measures, the report concluded.Click here for the journal source. Ou Y, Chopra V, Rosdahl JA, et al. Visual electrophysiology for the diagnosis of glaucoma. Ophthalmology. June 12, 2026. [Epub ahead of print]. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.