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Development and validation of a new glaucoma screening test using temporally modulated flicker

Fidalgo, B., Jindal, A., Tyler, C. W. ORCID: 0000-0002-1512-4626, Ctori, I. ORCID: 0000-0003-1523-4996 and Lawrenson, J. ORCID: 0000-0002-2031-6390 (2018). Development and validation of a new glaucoma screening test using temporally modulated flicker. OPHTHALMIC AND PHYSIOLOGICAL OPTICS, 38(6), pp. 617-628. doi: 10.1111/opo.12588


Describing the psychometric characteristics and diagnostic accuracy of the Accelerator 4‐Alternative Forced‐Choice Flicker Test prototype (A4FTp) for detecting chronic open angle glaucoma (COAG).

A4FTp measures temporally‐modulated flicker thresholds in regions of the visual field with high susceptibility to glaucomatous loss. We initially evaluated its psychometric properties on 20 normals (aged 33.8 ± 8.5 years) who were tested multiple times over a period of 3 months. All subjects underwent four repetitions for shorter (T8) and longer (T12) staircase termination criteria, to determine the most suitable threshold criterion. Four randomly selected subjects underwent a total of 10 repetitions to study test‐retest repeatability and learning effects. To determine its diagnostic accuracy, one eye of 40 participants with COAG and 38 normal controls were tested with the A4FTp in comparison with the Frequency Doubling Technology (FDT; C20‐5 programme) and iVue Spectral Domain Optical Coherence Tomography (SD‐OCT). Tests were conducted in a random order with results masked to the clinician conducting the reference ophthalmic examination. The accuracy of each test was determined by analysis of the area under the receiver operator characteristic curve (AUROC).

A4FTp flicker thresholds were stable, with standard deviations of only 0.52 decilog (dL) for T8, increasing to 1.32 dL for T12, and no significant flicker sensitivity threshold improvement over the 10 repeat runs. T8 was superior to T12 on several other measures, so it was used for the remaining comparisons. In terms of diagnostic accuracy, the mean AUROC for the three tests were A4FTp [T8 criterion; 0.82, 95% confidence interval (0.73–0.92)]; SD‐OCT [any RNFL parameter p < 1% level; 0.90 (0.83–0.97)]; and FDT [one or more locations missed at p < 5% level; 0.91 (0.82–0.96)]. There was no statistical difference in AUROC between A4FTp and SD‐OCT (p = 0.18) or FDT (p = 0.12). The A4FTp test duration averaged just over 2 min per eye, taking approximately one‐third of the time for completion of the HFA SITA 24‐2 algorithm (conducted as part of the reference examination) and twice the time for the suprathreshold FDT.

Test accuracy for the A4FTp was comparable to those of the FDT and SD‐OCT for the detection of COAG. Time taken to complete the A4FTp was relatively short and initial results are promising. With further refinement, the A4FTp could have a future role in glaucoma detection.

Publication Type: Article
Additional Information: This is the peer reviewed version of the following article: Fidalgo BR, Jindal A, Tyler CW, Ctori I & Lawrenson JG. Development and validation of a new glaucoma screening test using temporally modulated flicker. Ophthalmic Physiol Opt 2018; 38: 617–628, which has been published in final form at This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.
Subjects: R Medicine > RE Ophthalmology
Departments: School of Health Sciences > Optometry & Visual Science
[img] Text - Accepted Version
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