Low Sensitivity of the Van Herick Method for Detecting Gonioscopic Angle Closure Independent of Observer Expertise

Purpose: To evaluate the diagnostic performance characteristics of the Van Herick assessment (VHA) for identifying angle closure compared to gold-standard gonioscopy, as conducted by trained observers of varying expertise. Design: Reliability analysis. Methods: Patients (n = 131) from a glaucoma referral clinic aged ≥50 years without prior ocular surgery or iridotomy underwent unilateral VHA by 1 of 11 trained ophthalmic technicians, followed by VHA and indirect gonioscopy by 1 of 15 ophthalmology residents and 1 of 4 glaucoma specialist attending physicians. Observers were masked to others’ gradings. Cohen's kappa (κ) assessed test reproducibility. VHA sensitivity and specificity for identifying gonioscopic angle closure were calculated. Results: Mean patient age was 62.0 ± 8.7 years, 56% of patients were male, and 84% were African American. Angles were gonioscopically closed in 14.5% of eyes. Moderate agreement was observed comparing technician or resident VHA to attending VHA (κ = 0.48 and κ = 0.56, respectively). Resident and attending gonioscopy demonstrated excellent agreement (κ = 0.94). Sensitivities of technician, resident, and attending VHA for detecting angle closure were 57.9% (95% confidence interval: 34.0%–78.9%), 78.9% (53.9%–93.0%), and 68.4% (43.5%–86.4%), respectively. Specificities were 88.5% (80.3%–93.6%), 88.2% (80.3%–93.3%), and 87.5% (79.6%–92.8%), respectively. Conclusions: VHA, even when performed by experienced ophthalmologists, misses a substantial proportion of angle closure while incorrectly identifying roughly 1 in 8 open-angle eyes as closed. These results suggest that clinical assessment of anterior chamber angle configuration is best accomplished with gonioscopy.