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

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Abstract

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.

Original languageEnglish (US)
Pages (from-to)63-71
Number of pages9
JournalAmerican Journal of Ophthalmology
Volume195
DOIs
StatePublished - Nov 1 2018

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Gonioscopy
Glaucoma
Anterior Chamber
Ophthalmology
Gold
African Americans
Referral and Consultation
Confidence Intervals
Physicians
Sensitivity and Specificity

ASJC Scopus subject areas

  • Ophthalmology

Cite this

@article{01b91051662547dba3ebbb1689cd91e8,
title = "Low Sensitivity of the Van Herick Method for Detecting Gonioscopic Angle Closure Independent of Observer Expertise",
abstract = "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.",
author = "Thomas Johnson and Pradeep Ramulu and Quigley, {Harry A} and Singman, {Eric L}",
year = "2018",
month = "11",
day = "1",
doi = "10.1016/j.ajo.2018.07.026",
language = "English (US)",
volume = "195",
pages = "63--71",
journal = "American Journal of Ophthalmology",
issn = "0002-9394",
publisher = "Elsevier USA",

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TY - JOUR

T1 - Low Sensitivity of the Van Herick Method for Detecting Gonioscopic Angle Closure Independent of Observer Expertise

AU - Johnson, Thomas

AU - Ramulu, Pradeep

AU - Quigley, Harry A

AU - Singman, Eric L

PY - 2018/11/1

Y1 - 2018/11/1

N2 - 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.

AB - 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.

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