Screening for Glaucoma in High-Risk Populations Using Optical Coherence Tomography

doi:10.1016/j.ophtha.2009.07.033

Ophthalmology

Volume 117, Issue 3, March 2010, Pages 453-461

https://doi.org/10.1016/j.ophtha.2009.07.033 Get rights and content

Objective

To estimate the diagnostic accuracy of Stratus optical coherence tomography (OCT) for glaucoma screening in high-risk populations.

Design

Cross-sectional evaluation of a diagnostic test for screening.

Participants

Three hundred thirty-three community-based volunteer participants with risk factors for glaucoma.

Methods

The optic nerve and peripapillary retinal nerve fiber layer (RNFL) of participants' eyes were scanned using the Stratus OCT. Based on an ophthalmologic examination and frequency doubling perimetry, eyes were classified into 4 categories: normal, possible glaucoma, probable glaucoma, and definitive glaucoma.

Main Outcome Measures

The sensitivities, specificities, positive and negative likelihood ratios of the RNFL, optic disc parameters, and their combinations were calculated.

Results

The right eyes were retained for analyses. After excluding eyes with missing data or with poor quality scans, the data of 210 right eyes were analyzed. Six eyes had definitive glaucoma. Combining the best performing optic nerve head parameters (cup diameter or cup/disc vertical ratio or cup/disc area ratio) and RNFL parameters (superior average or inferior average or overall average) using AND-logic resulted in a sensitivity of 67% (95% confidence interval [CI], 24%–94%), specificity of 96% (95% CI, 92%–98%), a positive likelihood ratio of 17.08 (95% CI, 7.06–41.4), and a negative likelihood ratio of 0.35 (95% CI, 0.11–1.08).

Conclusions

When adequate quality scans may be obtained, the Stratus has moderate sensitivity and high specificity for definitive glaucoma. Specificity is increased when parameters from both the optic nerve head and RNFL scans are combined.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Methods

The Standards for Reporting of Diagnostic Accuracy were reviewed and followed.²⁵

Results

All subjects met ≥1 high-risk inclusion criterion. Of 333 participants who were examined, 30 were excluded owing to missing data: 7 subjects had a missing FDT VF and 23 had missing Stratus scans. Of the remaining 303 patients, 51 were examined and tested at the hospital (Rosemont pavilion where the eye clinic was located until 2005), 77 were examined and tested at the new ambulatory eye clinic of the hospital (Centre de santé ambulatoire, which opened in 2005), 127 at the Glaucoma Institute of

Discussion

Glaucoma imaging is currently used as an adjunct to other clinical parameters important in glaucoma diagnosis and progression.³³ The performance of the Stratus for glaucoma detection has been evaluated in patients followed in eye clinics. Within this population, the sensitivity of the best performing RNFL parameters ranges between 75% and 85% for specificities >88%.17, 22, 34, 35, 36, 37 However, patients followed in eye clinics by glaucoma specialists have more advanced disease than in a

Acknowledgments

The authors thank Miguel Chagnon, PhD, for his statistical help.

References (50)

R. Varma et al.
Prevalence of open-angle glaucoma and ocular hypertension in Latinos: the Los Angeles Latino Eye Study
Ophthalmology
(2004)
W.F. Hoyt et al.
The earliest observable defect in glaucoma?
Lancet
(1972)
R.S. Parikh et al.
Diagnostic capability of optical coherence tomography (Stratus OCT 3) in early glaucoma
Ophthalmology
(2007)
K. Nouri-Mahdavi et al.
Identifying early glaucoma with optical coherence tomography
Am J Ophthalmol
(2004)
A. Bayer et al.
Validity of a new disk grading scale for estimating glaucomatous damage: correlation with visual field damage
Am J Ophthalmol
(2002)
P.J. Harasymowycz et al.
Validity of screening for glaucomatous optic nerve damage using confocal scanning laser ophthalmoscopy (Heidelberg Retina Tomograph II) in high-risk populations: a pilot study
Ophthalmology
(2005)
K.E. Cello et al.
Frequency doubling technology perimetry for detection of glaucomatous visual field loss
Am J Ophthalmol
(2000)
D.F. Garway-Heath et al.
Mapping the visual field to the optic disc in normal tension glaucoma eyes
Ophthalmology
(2000)
S.C. Lin et al.
Optic nerve head and retinal nerve fiber layer analysis: a report by the American Academy of Ophthalmology
Ophthalmology
(2007)
F.A. Medeiros et al.
Evaluation of retinal nerve fiber layer, optic nerve head, and macular thickness measurements for glaucoma detection using optical coherence tomography
Am J Ophthalmol
(2005)

G. Wollstein et al.

Comparison of three optical coherence tomography scanning areas for detection of glaucomatous damage

Am J Ophthalmol

(2005)

A.U. Bayer et al.

Short wavelength automated perimetry, frequency doubling technology perimetry, and pattern electroretinography for prediction of progressive glaucomatous standard visual field defects

Ophthalmology

(2002)

F.A. Medeiros et al.

Frequency doubling technology perimetry abnormalities as predictors of glaucomatous visual field loss

Am J Ophthalmol

(2004)

Prevalence of open-angle glaucoma among adults in the United States

Arch Ophthalmol

(2004)

The screening of primary open-angle glaucoma

Screening for glaucoma: recommendation statement

Ann Fam Med

(2005)

C. Fleming et al.

Screening for primary open-angle glaucoma in the primary care setting: an update for the US Preventive Services Task Force

Ann Fam Med

(2005)

A. Sommer et al.

Relationship between intraocular pressure and primary open angle glaucoma among white and black Americans: the Baltimore Eye Survey

Arch Ophthalmol

(1991)

J.M. Tielsch et al.

Family history and risk of primary open angle glaucoma: the Baltimore Eye Survey

Arch Ophthalmol

(1994)

B. Nemesure et al.

Analyses of reported family history of glaucoma: a preliminary investigation

Ophthalmic Epidemiol

(1996)

R.C. Wolfs et al.

Genetic risk of primary open-angle glaucoma: population-based familial aggregation study

Arch Ophthalmol

(1998)

R. Hernandez et al.

Screening for open angle glaucoma: systematic review of cost-effectiveness studies

J Glaucoma

(2008)

A. Sommer et al.

Optic disc parameters and onset of glaucomatous field loss: IMethods and progressive changes in disc morphology

Arch Ophthalmol

(1979)

J. Funk

Early detection of glaucoma by longitudinal monitoring of the optic disc structure

Graefes Arch Clin Exp Ophthalmol

(1991)

M. Motolko et al.

Features of the optic disc in preglaucomatous eyes

Arch Ophthalmol

(1981)

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Citation Excerpt :
One of our starting points was that it is possible that relatives of glaucoma patients have fewer retinal ganglion cells at the start of their lives and are therefore more likely to display thinner retinal layers. In contrast to previous reports, we included only young adults in order to eliminate age-related glaucoma risk [5,6]. We hypothesized that new early diagnostic techniques may show some defects in the posterior pole retina of young relatives of POAG patients.
The presence of a family history of glaucoma is a known risk factor for primary open-angle glaucoma (POAG) in middle-aged and older individuals. In this study, our aim was to demonstrate possible early glaucomatous alterations in young first- and second-degree relatives of POAG patients by spectral-domain optical coherence tomography. A total of 104 participants (52 relatives of POAG patients and 52 healthy individuals) were recruited in this cross-sectional study. All the participants were between 17 years and 45 years of age. All eyes underwent testing with spectral-domain optical coherence tomography. Peripapillary retinal nerve fiber layer thickness, hemifield macular thickness, macular ganglion cell complex thickness, posterior pole asymmetry analysis, and retinal arteriolar caliber measurements were taken for comparison between the study and control groups. The mean peripapillary retinal nerve fiber layer thickness was 104.9 ± 8.8 μm in the study group and 105.6 ± 7.4 μm in the control group (p = 0.68). Although whole macular thickness measurements were higher in the control group when compared with the study group (p = 0.008), the macular ganglion cell complex thickness was similar in both groups (p = 0.87). The posterior pole asymmetry analysis revealed no statistically significant difference between the groups in the aspect of consecutive black squares (p = 0.79). The mean retinal arteriolar caliber was 85.9 ± 4.8 μm in the study group and 86.0 ± 5.0 μm in the control group (p = 0.90). In conclusion, young relatives of POAG patients do not show characteristic glaucomatous damage when compared with the controls.
Screening for Glaucoma
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Likelihood ratios for glaucoma diagnosis using spectral-domain optical coherence tomography
2013, American Journal of Ophthalmology
To present a methodology for calculating likelihood ratios for glaucoma diagnosis for continuous retinal nerve fiber layer (RNFL) thickness measurements from spectral-domain optical coherence tomography (spectral-domain OCT).
Observational cohort study.
A total of 262 eyes of 187 patients with glaucoma and 190 eyes of 100 control subjects were included in the study. Subjects were recruited from the Diagnostic Innovations Glaucoma Study. Eyes with preperimetric and perimetric glaucomatous damage were included in the glaucoma group. The control group was composed of healthy eyes with normal visual fields from subjects recruited from the general population. All eyes underwent RNFL imaging with Spectralis spectral-domain OCT. Likelihood ratios for glaucoma diagnosis were estimated for specific global RNFL thickness measurements using a methodology based on estimating the tangents to the receiver operating characteristic (ROC) curve.
Likelihood ratios could be determined for continuous values of average RNFL thickness. Average RNFL thickness values lower than 86 μm were associated with positive likelihood ratios (ie, likelihood ratios greater than 1), whereas RNFL thickness values higher than 86 μm were associated with negative likelihood ratios (ie, likelihood ratios smaller than 1). A modified Fagan nomogram was provided to assist calculation of posttest probability of disease from the calculated likelihood ratios and pretest probability of disease.
The methodology allowed calculation of likelihood ratios for specific RNFL thickness values. By avoiding arbitrary categorization of test results, it potentially allows for an improved integration of test results into diagnostic clinical decision making.
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2011, American Journal of Ophthalmology
Citation Excerpt :
Thus, appropriate clinical acumen in the application of testing will naturally increase test usefulness. Sophisticated arguments have been made that combinations of tests may improve the performance of any single test in isolation, with the identification of clinically relevant changes after integrating diverse measures (such as computerized perimetry data with HRT or OCT imaging)—but often these efforts show only equivocal sensitivities and specificities.62–71 The few population-based attempts to improve on the detection of glaucoma using this integrative strategy have not been very successful.9
To assess the noneconomic value of tests used in the diagnosis and management of glaucoma, and explore the contexts and factors that determine such value.
Perspective.
Selected articles from primary and secondary sources were reviewed and interpreted in the context of the authors' clinical and research experience, influenced by our perspectives on the tasks of reducing the global problem of irreversible blindness caused by glaucoma. The value of any test used in glaucoma is addressed by 3 questions regarding: its contexts, its kind of value, and its implicit or explicit benefits.
Tonometry, slit-lamp gonioscopy, and optic disc evaluation remain the foundation of clinic-based case finding, whether in areas of more or less abundant resources. In resource-poor areas, there is urgency in identifying patients at risk for severe functional loss of vision; screening strategies have proven ineffective, and efforts are hindered by the inadequate allocation of support. In resource-abundant areas, the wider spectrum of glaucoma is addressed, with emphasis on early detection of structural changes of little functional consequence; these are increasingly the focus of new and expensive technologies whose clinical value has not been established in longitudinal and population-based studies. These contrasting realities in part reflect differences among the value ascribed, often implicitly, to the tests used in glaucoma.
The value of any test is determined by 3 aspects: its context of usage; its comparative worth and to whom its benefit accrues; and how we define historically what we are testing. These multiple factors should be considered in the elaboration of priorities for the development and application of tests in glaucoma.
Telemedicine for glaucoma: the state-of-the-art and trends of development
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: Manuscript no. 2009-300.

Financial Disclosure(s): The authors have made the following disclosures:

Gisèle Li - research funding, consultant/advisor and lecture – Allergan; consultant/advisor and lecture fees – Pfizer; consultant/advisor fees – Alcon; lecture fees - Merck & Co.

Paul Harasymowycz - consultant/advisor and lecture fees - Allergan, Alcon, Pfizer, and Merck & Co; consultant fees - SOLX.

: The funding organizations had no role in the design or conduct of this research.

: Supported by Fonds de la recherche en santé du Québec and Allergan, Irvine, CA. The funding organization had no role in the design or conduct of this research.

View full text

Original articleScreening for Glaucoma in High-Risk Populations Using Optical Coherence Tomography

Objective

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Financial Disclosure(s)

Section snippets

Methods

Results

Discussion

Acknowledgments

Ophthalmology

Lancet

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Prevalence of open-angle glaucoma among adults in the United States

Arch Ophthalmol

The screening of primary open-angle glaucoma

Screening for glaucoma: recommendation statement

Ann Fam Med

Screening for primary open-angle glaucoma in the primary care setting: an update for the US Preventive Services Task Force

Ann Fam Med

Relationship between intraocular pressure and primary open angle glaucoma among white and black Americans: the Baltimore Eye Survey

Arch Ophthalmol

Family history and risk of primary open angle glaucoma: the Baltimore Eye Survey

Arch Ophthalmol

Analyses of reported family history of glaucoma: a preliminary investigation

Ophthalmic Epidemiol

Genetic risk of primary open-angle glaucoma: population-based familial aggregation study

Arch Ophthalmol

Screening for open angle glaucoma: systematic review of cost-effectiveness studies

J Glaucoma

Optic disc parameters and onset of glaucomatous field loss: IMethods and progressive changes in disc morphology

Arch Ophthalmol

Early detection of glaucoma by longitudinal monitoring of the optic disc structure

Graefes Arch Clin Exp Ophthalmol

Features of the optic disc in preglaucomatous eyes

Arch Ophthalmol

Original article
Screening for Glaucoma in High-Risk Populations Using Optical Coherence Tomography