Frontloading Method Led to Six Reliable VFs Over 14 Months Sooner

In a clinical scenario where patients return unreliable VF results, a frontloading approach provides savings in terms of number of clinical visits and time required to attain evidence-based recommended numbers of tests for glaucoma monitoring. Click image to enlarge. In two years, three visual field (VF) tests per year are required to detect relatively fast progression (-2dB per year) in patients with average visual field variability. This proposal emphasizes the detection of relatively fast progressors, but if considering median progression rates at the cohort level, there need to be even more tests performed to identify such cases. Researchers from the University of New South Wales in Australia have continued to test their “frontloading” approach, which involves two VF tests per eye at each visit, as opposed to only at the first visit, such as to establish a baseline. In their recent study published in Ophthalmology Glaucoma, the team analyzed the number of VF tests attained in a clinical cohort of subjects, comparing this with evidence-based recommendations. They determined that the frontloading approach overall led to savings in time and cost in comparison to non-frontloading for achieving six reliable VFs and thus potentially provides an avenue for earlier detection of glaucomatous change.The study used 10,010 SITA-Faster VF tests of 535 clinical subjects, of which 8,931 had a false positive rate ≤15%. Approximately 90% of subjects had early or moderate open-angle glaucoma.When using the frontloading protocol, it took an average of 1.4 years to attain six reliable VFs for the right and left eyes, respectively. For the non-frontloaded protocol, the average times were 2.6 years and 2.5 years for right and left eyes, respectively. 82.5% of right eyes and 85.4% of left eyes achieved six reliable VFs within two years when frontloaded, but the proportion was only 15.8% and 18.8% when non-frontloaded for right and left eyes, respectively. The average total number of 24-2 tests performed per visit over the follow-up duration was 3.6, so it was uncommon for more than two tests to have been performed per eye.The frontloading approach mitigates the issue of tailoring testing given limited information by recommending at least two tests per eye per patient unless there is a clinical decision made otherwise. This approach is helpful in the workflow, as it ensures that all testing is completed while the patient is already in the perimetry suite and while the test instructions are fresh.“The empirical data in the present study allowed us to plot the number of cumulative tests at different time points, highlighting that the critical number of reliable visual field tests can be achieved within the first two years of follow-up for most patients using the frontloading approach,” the study authors wrote in their paper.Even accounting for a 20% increased patient load achievable with within-visit time savings when non-frontloading, the frontloaded approach was still monetarily less expensive, owing to the overall fewer absolute numbers of visits required to achieve visual field targets.The researchers did note that their results were only generalizable to patients with early to moderate glaucoma. The needs of patients with more advanced stages of glaucoma may be different, but the team still believes that they may be even more likely to benefit from more visual field tests to monitor their disease trajectory.Original abstract content ©2025 Association for Research in Vision and Ophthalmology. Wang H, Masselos K, Tan JCK, et al. The frontloading approach to meet guideline-recommended visual field testing for glaucoma: time and cost. Ophthalmol Glaucoma. April 11, 2025. [Epub ahead of print].