Diagnostic Ability of Heidelberg Retina Tomograph 3 Classifications: Glaucoma Probability Score versus Moorfields Regression Analysis

doi:10.1016/j.ophtha.2007.01.015

Ophthalmology

Volume 114, Issue 11, November 2007, Pages 1981-1987.e1

https://doi.org/10.1016/j.ophtha.2007.01.015 Get rights and content

Purpose

To evaluate the usefulness of the glaucoma probability score (GPS), which does not require manual outlining of the disc boundaries, and the Moorfields regression classification (MRA), which requires manual outlining of the disc boundaries, for discriminating between healthy and glaucomatous eyes, using the Heidelberg Retina Tomograph.

Design

Cross-sectional study.

Participants

We prospectively selected 71 consecutive healthy subjects and 115 consecutive patients with open-angle glaucoma.

Methods

Participants were divided into 2 groups depending on the results of standard automated perimetry and intraocular pressure. All participants underwent imaging of the optic nerve head with the Heidelberg Retina Tomograph 3. All tests were performed within 1 month of each subject’s date of enrollment into the study by examiners masked to the other findings.

Main Outcome Measures

The sensitivity and specificity of all parameters of the MRA and GPS classifications were calculated. The diagnostic accuracy at different severities of glaucoma and optic disc sizes was also evaluated. Receiver operating characteristic curves were plotted for the GPS values.

Results

The MRA global classification had a sensitivity of 73.9% and a specificity of 91.5%. The GPS global classification had a sensitivity of 58.2% and a specificity of 94.4%. The GPS had slightly higher sensitivity and somewhat lower specificity than the MRA when there was mild damage indicated by visual field tests. The MRA had the best discrimination capability for moderate and severe glaucoma. Both the GPS and MRA had lower sensitivity and higher specificity for small optic discs (<1.7 mm²) compared with medium and large discs.

Conclusions

In general, the diagnostic performance of the GPS was similar to that of the MRA. The diagnostic accuracy of both classifications depends on the optic disc size and the glaucoma severity.

Section snippets

Subjects and Measurement Protocol

The prospective study protocol was approved by the ethics committee of Miguel Servet University Hospital, and written consent was obtained from all participants. The design of the study followed the tenets of the Declaration of Helsinki for biomedical research.

A total of 201 eyes of 201 consecutive subjects were prospectively preenrolled from January 2006 to June 2006. Two of the subjects did not provide informed consent; 2 subjects did not complete all of the required tests; and 3 subjects

Results

The normal group included 71 eyes of 71 subjects. The mean age was 59.0±9.8 years. The glaucoma group included 115 eyes of 115 patients: 84 with primary open-angle glaucoma, 24 with pseudoexfoliative glaucoma, and 7 with pigmentary glaucoma. The mean age was 61.0±7.2 years. Neither age (P = 0.077) nor central corneal thickness (P = 0.170) differed significantly between the groups.

Table 1 presents the clinical characteristics of the study population. There were significant differences in mean

Discussion

The ability of the HRT to detect glaucomatous changes of the optic nerve head has been widely validated. Previous studies5, 8, 9, 10, 12, 14, 26, 27, 28, 29 determined the best parameters for discriminating between healthy and glaucomatous eyes. The HRT is easy to perform, provides quantitative data, and does not usually require mydriasis (depending on pupil size). Outcomes based on a normative database, such as the MRA and GPS classifications, offer an initial approach to glaucoma diagnosis.

References (34)

H.A. Quigley
Neuronal death in glaucoma
Prog Retin Eye Res
(1999)
K. Rohrschneider et al.
Reproducibility of the optic nerve head topography with a new laser tomographic scanning device
Ophthalmology
(1994)
M. Iester et al.
The effect of optic disc size on diagnostic precision with the Heidelberg retina tomograph
Ophthalmology
(1997)
G. Wollstein et al.
Identification of early glaucoma cases with the scanning laser ophthalmoscope
Ophthalmology
(1998)
A. Heijl et al.
Test-retest variability in glaucomatous visual fields
Am J Ophthalmol
(1989)
J. Caprioli
Automated perimetry in glaucoma
Am J Ophthalmol
(1991)
A. Tuulonen et al.
Initial glaucomatous optic disk and retinal nerve fiber layer abnormalities and their progression
Am J Ophthalmol
(1991)
A. Mistlberger et al.
Heidelberg retina tomography and optical coherence tomography in normal, ocular-hypertensive, and glaucomatous eyes
Ophthalmology
(1999)
S. Miglior et al.
Clinical ability of Heidelberg retina tomograph examination to detect glaucomatous visual field changes
Ophthalmology
(2001)
R.R. Wagner et al.
Continuous versus categorical data for ROC analysis: some quantitative considerations
Acad Radiol
(2001)

A. Kanamori et al.

Evaluation of glaucomatous damage on retinal nerve fiber layer thickness measured by optical coherence tomography

Am J Ophthalmol

(2003)

K. Nouri-Mahdavi et al.

Identifying early glaucoma with optical coherence tomography

Am J Ophthalmol

(2004)

S. Miglior et al.

Detection of glaucomatous visual field changes using the Moorfields regression analysis of the Heidelberg retina tomograph

Am J Ophthalmol

(2003)

Preferred Practice Pattern

P. Janknecht et al.

Optic nerve head analyser and Heidelberg retina tomograph: accuracy and reproducibility of topographic measurements in a model eye and in volunteers

Br J Ophthalmol

(1994)

F.S. Mikelberg et al.

Ability of the Heidelberg retina tomograph to detect early glaucomatous visual field loss

J Glaucoma

(1995)

L. Brigatti et al.

Correlation of visual field with scanning confocal laser optic disc measurements in glaucoma

Arch Ophthalmol

(1995)

Cited by (56)

Can an inexperienced observer accurately plot disc contours using Heidelberg retinal Tomograph?
2014, Canadian Journal of Ophthalmology
To examine the reliability of inexperienced observers in plotting optic disc contours on Heidelberg retinal tomography images before and after training.
Observational study.
One hundred eyes that were randomly selected from the Singapore Indian Eye Study.
Both eyes of subjects were imaged with Heidelberg Retina Tomograph 3 (HRT-3; Heidelberg Engineering, Heidelberg, Germany). Optic disc contours were plotted on the same images by 2 new observers on 2 separate occasions, before and after 2-hour standardized training on the skills and tools available to accurately identify and delineate optic disc contours. These plottings were compared with an experienced, trained glaucoma expert (gold standard). Agreement and variability were analyzed by interclass correlation tests and Bland–Altman plots.
A total of 182 images (18 excluded because of poor quality) from 89 Indian subjects were included. The mean age was 53.27 ± 7.25 years and 54.8% were male. There was moderate-to-high agreement between pretraining (both new observers) and experienced observer’s results (interclass correlation values range, 0.76–0.99). The interclass correlation improved for all the HRT-3 parameters after the 2 new observers were adequately trained. Comparing the interclass correlation values before and after training, the differences for mean retinal nerve fibre layer thickness for Observer 1 and all the HRT-3 parameters for Observer 2 were statistically significant.
This study shows that it is easy to train a new inexperienced observer to plot optic disc contours on HRT images, which translates into improved and acceptable interobserver variability and agreement.
Examen de la fiabilité d’observateurs inexpérimentés dans le tracé des contours de la papille optique dans les images de Tomographie rétinienne Heidelberg, avant et après leur formation.
Étude par observation.
100 yeux, qui ont été choisis au hasard dans l’Étude oculaire indienne de Singapore.
Les deux yeux des sujets ont été présentés en images par Tomographie rétinienne Heidelberg-3 (HRT, Heidelberg Engineering, Germany). Les contours des papilles optiques ont été tracés sur les mêmes images par 2 nouveaux observateurs à 2 occasions distinctes, d’abord avant puis après une formation formalisée de 2 heures quant aux talents requis et aux outils disponibles, pour identifier et tracer avec précision les contours de la papille optique. Ces tracés ont été comparés à ceux d’un expert du glaucome, formé et expérimenté (étalon-or). L’accord et la variabilité ont été analysés par des tests de corrélation interclasse et des graphiques de Bland-Altman.
182 images (18 exclusions pour piètre qualité) de 89 sujets Indiens ont été utilisées. La moyenne d’âge était de 53,27 ± 7,25 ans et 54,8 % étaient masculins. Il y eut une concordance allant de modérée à élevée des résultats entre les observateurs en préformation (deux nouveaux) et les observateurs expérimentés (les valeurs de la corrélation interclasse variait entre 0,76 et 0,99). La corrélation interclasse s’est améliorée pour tous les paramètres de la Tomographie rétinienne Heidelberg-3 après la formation adéquate des 2 nouveaux observateurs. En comparant les valeurs de corrélation interclasse avant et après la formation, les différences d’épaisseur moyenne de la couche de fibre nerveuse rétinienne de l’observateur 1 et de tous les paramètres de la Tomographie rétinienne Heidelberg-3 pour l’observateur 2 étaient statistiquement significatives.
Cette étude a montré qu’il était facile d’entrainer un nouvel observateur inexpérimenté pour tracer des contours de papille optique sur les images de Tomographie rétinienne Heidelberg, ce qui se traduit par l’amélioration et l’acceptation de variabilité et de l’entente entre les observateurs.
Measurement of Normal Optic Nerve Head Parameters
2012, Survey of Ophthalmology
Citation Excerpt :
Reports have documented mean optic disk areas of between 1.79 mm2 and 2.67 mm2 in normal populations,1,2,29,32,33,36,37,47–52,55,56,64–66,89,92,95,96,100,101,107,114,115,121,131,134,136,140,143,148,152,154,156,162,163,165–167,169,171,172,174,175,186 and mean optic cup areas have varied between 0.32 mm2 and 0.95 mm2 in different populations (Appendix 2).1,29,36,37,48–52,55,56,64,66,92,96,100,107,115,121,134,140,143,148,153,154,162,163,165–167,169,171,174,175,186 Mean cup-to-disk area ratio has been reported to lie between 0.19 to 0.37.1,28,29,33,36,37,48–52,56,66,92,96,100,107,114,115,121,134,140,143,153,154,162,163,165,166,169,171,174,175,186 Interestingly, only one report presents data on mean vertical disk and cup diameter derived by HRT; this quotes a mean vertical disk and cup diameter of 1.65 ± 0.20 mm and 0.81 ± 0.29 mm, respectively, from a sample of 62 Indian subjects.163
All optic nerve pathologies, including the glaucomas and disorders such as non-arteritic ischemic optic neuropathy, affect the appearance of the optic nerve head. Morphological examination of the optic nerve head in a qualitative and quantitative manner is therefore clinically mandatory. With the advent of modern imaging modalities such as confocal scanning laser tomography and optical coherence tomography, new diagnostic avenues have opened up to further refine the examination. The new imaging devices are now becoming a major adjunct to the diagnosis and long-term management of optic nerve head pathology; before it is possible to identify an abnormal optic disk, however, it is essential to understand the morphology and measurement of the normal disk. We summarize recent data on the normal morphology and measurement of optic nerve head parameters as assessed by the major imaging modalities now available.
Influence of disc size on optic nerve head versus retinal nerve fiber layer assessment for diagnosing glaucoma
2011, Ophthalmology
To explore and compare the influence of optic disc size on the diagnostic accuracy of retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) quantitative assessment.
Observational, cross-sectional evaluation of diagnostic tests.
We included 120 eyes from 50 normal subjects and 70 glaucomatous patients classified by the presence of a repeatable visual field defect for the analysis.
The RNFL thickness was measured by scanning laser polarimetry with variable corneal compensator (GDx-VCC, Carl-Zeiss Meditec, Dublin, CA) and spectral-domain optical coherence tomography (Cirrus HD-OCT, Carl Zeiss Meditec, Inc). We obtained ONH imaging by means of confocal scanning laser ophthalmoscopy (HRT3; Heidelberg Engineering, GmbH, Dossenheim, Germany).
Sensitivity and specificity for normative classifications, sensitivity at fixed specificity and area under the receiver operating characteristics curve (AUC) for continuous parameters. A logistic marginal regression model and coefficients of variation (CoV) have been used to test and quantify the influence of optic disc size on the diagnostic accuracy of the 3 technologies under investigation.
Among continuous parameters average RNFL thickness for Cirrus HD-OCT, nerve fiber indicator for GDx-VCC and cup shape measure for the HRT3 showed the best diagnostic accuracy with an AUC of 0.97, 0.94, and 0.94, respectively. Among normative classifications, the highest sensitivity and specificity were found for OCT average RNFL thickness (75.8% and 94.7%), for GDx superior thickness (77.1% and 97.5%), for HRT3 Moorfields regression analysis result (89.4% and 73.7%) and for HRT3 GPS global (92.3% and 76.5%). The diagnostic performance of HRT3 parameters seemed to be significantly influenced by optic disc size, although the same was not true for Cirrus HD-OCT and GDx VCC. The most steady performers for each imaging device across disc size groups were Cirrus HD-OCT average thickness (CoV, 1.6%), GDx-VCC inferior thickness (CoV, 2.5%), and HRT3 GPS temporal and nasal (CoV, 21.4%).
The diagnostic accuracy of quantitative RNFL assessment as performed by Cirrus HD-OCT and GDx-VCC is high and virtually unaffected or only minimally affected by the size of the optic disc and may provide more consistent diagnostic outcomes across small and large discs than ONH assessment as performed by HRT3.
The authors have no proprietary or commercial interest in any of the materials discussed in this article.
Screening for glaucoma with Moorfields regression analysis and glaucoma probability score in confocal scanning laser ophthalmoscopy
2011, Canadian Journal of Ophthalmology
To compare the validity of Moorfields regression analysis (MRA) and glaucoma probability score (GPS) of the confocal scanning laser ophthalmoscopy (Heidelberg retina tomograph 3; HRT3) in detecting glaucomatous optic nerve damage in a screening population.
Population-based, cross-sectional study.
Subjects at high risk for development of open-angle glaucoma (OAG).
All subjects underwent confocal scanning ophthalmoscopy (Heidelberg retina tomograph; HRTII) testing, visual fields testing with frequency-doubling technology perimetry (FDT), and a standard ophthalmologic examination. All HRTII images were reprocessed with HRT3. Based on an ophthalmologic examination and FDT results, eyes were classified into 4 categories: normal, possible glaucoma, probable glaucoma, and definitive glaucoma. Main outcome measures included sensitivity and specificity of HRTII/MRA, HRT3/MRA, HRT3/GPS, and combination HRT3/MRA/GPS.
The left eyes of 221 of 291 subjects were included; 4 (1.8%) eyes were classified as definitively having glaucoma. Depending on the reference standard diagnosis as well as on the borderline test-positive definition of the HRTII-3, sensitivity and specificity varied between 36.4% and 100%. For HRTII/MRA, 88.2% to 96.5%, 54.5% to 100%, and 74.5% to 93.6%; for HRT3/MRA, 61.9% to 100% and 64.3% to 85.2%; for HRT3/GPS, 85.7% to 100%; and for combination HRT3/MRA/GPS, 73.4% to 78.2%.
In this pilot study, the MRA of the HRT3 appears to be more sensitive but less specific than the MRA in the HRTII version. The GPS, although somewhat less specific than MRA (and some discs are nonclassifiable by this technique), had greater sensitivity and as a screening method may have the additional advantage of being contour-line independent.
Dépister le glaucome avec l'analyse de régression de Moorfields (ARM) et du score de probabilité du glaucome (SPG) dans l'ophtalmoscopie confocale à balayage laser (HRT3).
Étude transversale.
Sujets à haut risque de développement du glaucome à angle ouvert (GAO).
Les sujets ont subi le HRTII, la périmétrie à doublage de fréquence (PDF) et l'examen ophtalmologique standard. Les images du HRTII ont été retraitées avec le HRT3. Sur la base des résultats de l'examen ophtalmologique et du PDF, les yeux ont été classés en 4 catégories: normaux, glaucome possible, glaucome probable, et glaucome définitif. Les mesures principales incluent la sensibilité et la spécificité du HRTII-MRA, HRT3-MRA, HRT3-GPS, et de leur combinaison HRT3-MRA-GPS.
Les yeux gauches de 221 de 291 sujets ont été inclus, dont 4 (1.8%) yeux ont été classés comme ayant un glaucome définitif. Dépendamment de la définition de la positivité limite du test du HRTII-3, la sensibilité et la spécificité varient entre 36.4% et 100%. Pour le HRTII/MRA entre 88.2% et 96.5%, entre 54.5% et 100%, et entre 74.5% et 93.6%; pour le HRT3/MRA, entre 61.9% et 100% et entre 64.3% et 85.2%; pour le HRT3-GPS entre 85.7% et 100%; et pour la combinaison HRT3-MRA-GPS, entre 73.4% et 78.2%.
Dans cette étude pilote, l'ARM du HRT3 apparait plus sensible, mais moins spécifique que l'ARM du HRTII. Le SPG, quoiqu'un peu moins spécifique que l'ARM, et que certains disques optiques soient non-classifiables, a une plus grande sensibilité et pourrait avoir un avantage additionnel comme méthode de dépistage d'être indépendant du tracé de ligne de contour.
Ophthalmic imaging for the diagnosis and monitoring of glaucoma: A review
2022, Clinical and Experimental Ophthalmology
Image processing based automated glaucoma detection techniques and role of de-noising: A technical survey
2019, Handbook of Multimedia Information Security: Techniques and Applications

View all citing articles on Scopus

: Manuscript no. 2006-809.

: The authors have no commercial or proprietary interest in the products of companies mentioned in the article.

View full text

Original articleDiagnostic Ability of Heidelberg Retina Tomograph 3 Classifications: Glaucoma Probability Score versus Moorfields Regression Analysis

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Subjects and Measurement Protocol

Results

Discussion

Prog Retin Eye Res

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

Acad Radiol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Preferred Practice Pattern

Optic nerve head analyser and Heidelberg retina tomograph: accuracy and reproducibility of topographic measurements in a model eye and in volunteers

Br J Ophthalmol

Ability of the Heidelberg retina tomograph to detect early glaucomatous visual field loss

J Glaucoma

Correlation of visual field with scanning confocal laser optic disc measurements in glaucoma

Arch Ophthalmol

Original article
Diagnostic Ability of Heidelberg Retina Tomograph 3 Classifications: Glaucoma Probability Score versus Moorfields Regression Analysis