Preferential Hyperacuity Perimetry: Perspectives of Self-Monitoring of Neovascular Activity in Patients with Age-Related Macular Degeneration

Francesco Parmeggiani*

Corresponding Author

Francesco Parmeggiani, MD, PhD

Department of Biomedical and Specialty Surgical Sciences University of Ferrara Ferrara, Italy; Tel. (+39) 532 688142; Fax: (+39) 532 247365; E-mail:


Francesco Parmeggiani, MD, PhD*

Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy

Corresponding Author

Francesco Parmeggiani, MD, PhD

Department of Biomedical and Specialty Surgical Sciences University of Ferrara Ferrara, Italy; Tel. (+39) 532 688142; Fax: (+39) 532 247365; E-mail:

Article History

Received: October 18th, 2015 Accepted: October 19th, 2015 Published: October 20th, 2015

Cite this Article

Parmeggiani F. Preferential hyperacuity perimetry: perspectives of self-monitoring of neovascular activity in patients with age-related macular degeneration. Ophthalmol Open J. 2015; 1(1): e3-e5. doi: 10.17140/OOJ-1-e002


© 2015 Parmeggiani F. This is an open access article distributed under the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



The socio-economic burden of age-related macular degeneration (AMD) has strongly increased in public health importance due to the aging of the general population, and in clinics because of the world-wide use of anti-vascular endothelial growth factor (anti-VEGF) drugs in patients with neovascular AMD (NV-AMD).1,2,3,4,5 In all health care services of the developed countries, a large portion of NV-AMD burden is related to the growing human resources employed to carry out those frequent monitoring visits required to verify the necessity of anti-VEGF repetition. In view of recent findings in earlier diagnosis of AMD-related choroidal neovascularization (CNV) by means of the self-monitoring with preferential hyperacuity perimetry (PHP) device,6,7,8 possibilities and limitations of this innovative self-monitoring approach, whose rationale exploits the human “Vernier acuity” visual function,9,10 should be investigate to verify its ability in detecting the need for anti-VEGF retreatments among patients with NV-AMD, and to prospectively reduce the costs for the clinical governance of this sight-threatening disease.

AMD is the leading cause of irreversible vision loss and legal blindness in the developed countries.5,11 Before the large-scale utilization of intravitreally injected anti-VEGF drugs in the everyday clinical practice, NV-AMD accounts for more than 80% of the cases of severe visual deterioration caused by AMD.12,13 At present, appropriate anti-VEGF utilization makes possible an outstanding reduction of patients eligible for legal blindness certification,14,15,16 maintaining or improving their vision-related quality of life.17,18,19 However, none of these benefits can be obtained without scheduling periodic anti-VEGF retreatments, whose correct decision making process is practicable only after the execution of frequent monitoring visits because of: i. the limited intravitreal duration of the administered anti-VEGF drug; ii. the unpredictability of individual NV-AMD response to all different anti-VEGF regimens. In fact, considering the lack of a validated best clinical practice for anti-VEGF therapy in NV-AMD20 and the risk of dramatic vision loss related to the protraction of follow-up intervals,21 an intensive clinical monitoring of NV-AMD patients is currently mandatory to maintain the best outcomes possible, with consequent exponential growing of Medicare costs for the management of anti-VEGF injections regardless of the drug utilized during these interventional invasive procedures. The comprehensive appraisal of these aspects strongly recommends the realization large and independent clinical studies in view of the fact that PHP devices might also be an effective self- monitoring strategy to assess CNV activity in NV-AMD patients, allowing a substantial reduction of the socio-sanitary burden due to the great number of monitoring visits required for a correct application of anti-VEGF regimen, without risk of irreversible visual loss and legal blindness for an unmonitored extension of the monthly follow-up intervals. However, the appropriate utilization of PHP device for patient’s self-monitoring in real-world setting could be feasible only after the acquisition of well-detailed data regarding its potential and limitations in a large population of NV-AMD patient. In particular, future investigations should be aimed to: i. assess the ability of a self-monitoring test based on PHP to detect the need for retreatment with intravitreal anti-VEGF drugs in NV-AMD patients using, as gold standard, the ophthalmologist’s yes/no therapeutic decision after monitoring visits performed in accordance with good clinical practice; ii. verify whether the PHP monitoring data are influenced by individual demographic, clinical and ocular characteristics, which might be able to decrease the reliability of the test as a consequence of inadequate learning capacity, functional ability and/or compliance of each different NV-AMD patient treated with PRN anti-VEGF regimen.

Although the large-scale utilization of anti-VEGF drugs has made possible a reduction of up to 50% in incidence of legal blindness, the growing burden related to the appropriate monitoring of NV-AMD candidates for these treatment courses is becoming unsustainable for health care services. This emerging public health issue is currently faced without be aware of the potential applications of the innovative self-monitoring PHP device which, in turn, has been successfully utilized for the earlier detection of AMD-related CNV occurrence.6 Considering the lack of large, population-based, studies assessing the accuracy of PHP device in patient’s self-recognition of anti-VEGF retreatment necessity for NV-AMD, specific observational health care researches is recommended to provide those real-world clinical data helpful to maintain the best outcomes possible, yet rationally reduce the management cost of a chronic disease that reduces our accessibility to others in need.

NV-AMD represents a major burden to the modern society, and its all-inclusive cost for National Health Systems is continuously growing in terms of prevention, diagnosis, treatment, and rehabilitation. Diagnostic strategies for appropriate check of NV-AMD patients periodically treated with anti-VEGF injections are very expensive, posing a big translational emphasis on those innovative self-monitoring approaches developed to improve the methodological strategies for the surveillance of chronic sight threatening diseases. However, although some pilot studies have shown that PHP device is a very promising tool to improve the early diagnosis of NV-AMD,22,23,24 large-scale outcomes research programs will need to demonstrate that unconventional procedures for NV-AMD monitoring are methodologically robust and, thus, applicable in the real-world practice, also considering their tele diagnostic potential if integrated into modern data transaction systems.


The author declares no conflicts of interest.

1. Day S, Acquah K, Lee PP, Mruthyunjaya P, Sloan FA. Medicare costs for neovascular age-related macular degeneration, 1994-2007. Am J Ophthalmol. 2011; 152(6): 1014-1020. doi: 10.1016/j.ajo.2011.05.008

2. Qualls LG, Hammill BG, Wang F, et al. Costs of newly diagnosed neovascular age-related macular degeneration among medicare beneficiaries, 2004-2008. Retina. 2013; 33(4): 854-861. doi: 10.1097/IAE.0b013e31826f065e

3. Haller JA. Current anti-vascular endothelial growth factor dosing regimens: benefits and burden. Ophthalmology. 2013; 120(5 Suppl): S3-S7. doi: 10.1016/j.ophtha.2013.01.057

4. Jonas JB. Global prevalence of age-related macular degeneration. Lancet Glob Health. 2014; 2(2): e65-e66. doi: 10.1016/S2214-109X(13)70163-3

5. Wong WL, Su X, Li X, et al. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. Lancet Glob Health. 2014; 2(2): e106-e116. doi: 10.1016/S2214-109X(13)70145-1

6. Chew EY, Clemons TE, Bressler SB, et al. AREDS2-HOME Study Research Group. Randomized trial of a home monitoring system for early detection of choroidal neovascularization home monitoring of the Eye (HOME) study. Ophthalmology. 2014; 121(2): 535-544. doi: 10.1016/j.ophtha.2013.10.027

7. Faes L, Bodmer NS, Bachmann LM, Thiel MA, Schmid MK. Diagnostic accuracy of the Amsler grid and the preferential hyperacuity perimetry in the screening of patients with age-related macular degeneration: systematic review and meta-analysis. Eye (Lond). 2014; 28(7): 788-796. doi: 10.1038/eye.2014.104

8. Han DP. The ForeSeeHome device and the HOME study: a milestone in the self-detection of neovascular age-related macular degeneration. JAMA Ophthalmol. 2014; 132(10): 1167-1168. doi: 10.1001/jamaophthalmol.2014.1405

9. Westheimer G. Editorial: Visual acuity and hyperacuity. Invest Ophthalmol. 1975; 14(8): 570-572.

10. Alster Y, Bressler NM, Bressler SB, et al. Preferential Hyperacuity Perimetry Research Group. Preferential Hyperacuity Perimeter (PreView PHP) for detecting choroidal neovascularization study. Ophthalmology. 2005; 112(10): 1758-1765. doi: 10.1016/j. ophtha.2005.06.008

11. Bourne RR, Stevens GA, White RA, et al. Vision Loss Expert Group. Causes of vision loss worldwide, 1990-2010: a systematic analysis. Lancet Glob Health. 2013; 1(6): e339-e349. doi: 10.1016/S2214-109X(13)70113-X

12. Ferris FL 3rd, Fine SL, Hyman L. Age-related macular degeneration and blindness due to neovascular maculopathy. Arch Ophthalmol. 1984; 102(11): 1640-1642. doi: 10.1001/archopht.1984.01040031330019

13. Klein R, Peto T, Bird A, Vannewkirk MR. The epidemiology of age-related macular degeneration. Am J Ophthalmol. 2004; 137(3): 486-495. doi: 10.1016/j.ajo.2003.11.069

14. Bressler NM, Doan QV, Varma R, et al. Estimated cases of legal blindness and visual impairment avoided using ranibizumab for choroidal neovascularization: non-hispanic white population in the United States with age-related macular degeneration. Arch Ophthalmol. 2011; 129(6): 709-717. doi: 10.1001/archophthalmol.2011.140

15. Bloch SB, Larsen M, Munch IC. Incidence of legal blindness from age-related macular degeneration in Denmark: year 2000 to 2010. Am J Ophthalmol. 2012; 153(2): 209-213. doi: 10.1016/j.ajo.2011.10.016

16. Keenan TD, Kelly SP, Sallam A, Mohamed Q, Tufail A, Johnston RL. Incidence and baseline clinical characteristics of treated neovascular age-related macular degeneration in a well-defined region of the UK. Br J Ophthalmol. 2013; 97(9): 1168-1172. doi: 10.1136/bjophthalmol-2013-303233

17. Finger RP, Wiedemann P, Blumhagen F, Pohl K, Holz FG. Treatment patterns, visual acuity and quality-of-life outcomes of the WAVE study: a non-interventional study of ranibizumab treatment for neovascular age-related macular degeneration in Germany. Acta Ophthalmol. 2013; 91(6): 540-546. doi: 10.1111/j.1755-3768.2012.02493.x

18. Rakic JM, Leys A, Brié H, et al. Real-world variability in ranibizumab treatment and associated clinical, quality of life, and safety outcomes over 24 months in patients with neovascular age-related macular degeneration: the HELIOS study. Clin Ophthalmol. 2013; 7: 1849-1858. doi: 10.2147/OPTH.S49385

19. Finger RP, Guymer RH, Gillies MC, Keeffe JE. The impact of anti-vascular endothelial growth factor treatment on quality of life in neovascular age-related macular degeneration. Ophthalmology. 2014; 121(6): 1246-1251. doi: 10.1016/j.ophtha.2013.12.032

20. Han DP. Age-related macular degeneration, anti-VEGF therapy, and ophthalmic imaging: is there a best practice? JAMA Ophthalmol. 2013; 131(9): 1124-1126. doi: 10.1001/jamaophthalmol.2013.432

21. Tschuor P, Pilly B, Venugopal D, Gale RP. Optimising assessment intervals improves visual outcomes in ranibizumab-treated age-related neovascular degeneration: using the stability phase as a benchmark. Graefes Arch Clin Exp Ophthalmol. 2013; 251(10): 2327-2330. doi: 10.1007/s00417-013-2332-5

22. Das R, Shi Y, Silvestri G, Chakravarthy U. Distortion maps from preferential hyperacuity perimetry are helpful in monitoring functional response to Lucentis therapy. Retina. 2009; 29(7): 1013-1018. doi: 10.1097/IAE.0b013e3181a91dbf

23. Querques G, Berboucha E, Leveziel N, Pece A, Souied EH. Preferential hyperacuity perimeter in assessing responsiveness to ranibizumab therapy for exudative age-related macular degeneration. Br J Ophthalmol. 2011; 95(7): 986-991. doi: 10.1136/bjo.2010.190942

24. Querques G, Querques L, Rafaeli O, Canoui-Poitrine F, Bandello F, Souied EH. Preferential hyperacuity perimeter as a functional tool for monitoring exudative age-related macular degeneration in patients treated by intravitreal ranibizumab. Invest Ophthalmol Vis Sci. 2011; 52(9): 7012-7018. doi: 10.1167/iovs.11-7517


Laparoscopic Management of Adrenal and Extra-Adrenal

Laparoscopic Management of Adrenal and Extra-Adrenal Pheochromocytoma

Shrenik J. Shah*, Sajid Nurbhai, Rusha Surti, Parixit Malaviya and Pratik Chaudhary


Penile Cancer in the Region of Thies

Penile Cancer in the Region of Thies: Epidemiological, Diagnostic and Therapeutic Aspects

Saint C. N. Kouka*, Tonleu L. Bentefouet, Ngor M. Thiam, Modou Faye, Mbayang Diop, Mouhamed Cisse, Mohamed Jalloh, Aissatou A. Diame, Yoro Diallo and Sylla Cheikhna


Coronavirus Disease-2019 Infection-Associated Glomerular Diseases

Phuong-Chi T. Pham*, Golriz Jafari, Anita Kamarzarian, Vinod K. Valluri, Kulwant Bath, Chau Sally, Nguyen Tuan, Mahalli Joseph, Phuong-Mai T. Pham, Phuong-Anh T. Pham, Son V. Pham and Phuong-Thu T. Pham


West Virginia University Medicine, Wheeling Hospital’s Sepsis Study

Ramya Ramesh*, Jazmin Jatana, Chan Hong, Sathyanarayana Machani, Milind Awale, Stanley Guertal, Catherine Macalister, Heather L. Merkel, Melissa Burkett and Silvia Myndresku

doi. 10.17140/EMOJ-10-173

Yet Another Public Health Threat: A Commentary and Examination of the Extensive Use of Bromazolam

Nelson J. Tiburcio* and Scarlett L. Baker