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Editors Selection IGR 16-3

Clinical Examination Methods: Diagnostic Accuracy of OCT-A Macular Vessel Density

Comment by Leon Herndon on:

112613 Racial Differences in the Diagnostic Accuracy of OCT Angiography Macular Vessel Density for Glaucoma, Gunasegaran G; Gunasegaran G; Moghimi S; Nishida T et al. et al., Ophthalmology. Glaucoma, 2023; 0:

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The present study by Dr. Gunasegaran and colleagues compares the diagnostic accuracy for identifying primary open-angle glaucoma (POAG) with optical coherence tomography angiography (OCTA) derived macula vessel density and ganglion thickness between groups of individuals with self-reported African ancestry as compared to European ancestry.

The diagnostic accuracy is reduced in individuals with self-reported African descent as compared with individuals with self-reported European descent

The key result is that the diagnostic accuracy is reduced in individuals with self-reported African descent as compared with individuals with self-reported European descent. Macular ganglion cell analysis performed better than vessel density in identifying POAG in the study population and did not vary by self-reported descent. POAG in this study population was defined as glaucomatous visual field damage combined with masked assessment of stereoscopic optic nerve photography. All individuals underwent assessment with ophthalmic exam, intraocular pressure by Goldmann applanation, gonioscopy, pachymetry, optic disc photography, visual field testing and OCTA. OCTA images were used to analyze the density of blood vessels and ganglion cell thickness. The present study is of significant interest for assessing the clinical utility of OCTA in identification and management of POAG. Changes in vessel density have been proposed as a possible early marker of POAG progression with initial enthusiasm as an early biomarker for individuals with low-tension glaucoma. Individuals of African descent have a higher risk of POAG, and disparities between different racial and ethnic groups are a major concern among glaucoma specialists.

It is important to consider that the use of race or ethnicity as a factor in diagnosis or in clinical algorithms could have the unintentional consequence of worsening health disparities among groups with the possible propagation of stereotypes and biases

Over the past several years there has been an increased discussion of the utility and potential dangers of considering race or ethnicity in medical algorithms and diagnosis. It is important to consider that the use of race or ethnicity as a factor in diagnosis or in clinical algorithms could have the unintentional consequence of worsening health disparities among groups with the possible propagation of stereotypes and biases, concerns about discrimination, and concerns about equitable distribution of healthcare resources. However, not consistently studying differences stratified by ethnicity or race threatens to exacerbate healthcare disparities by assuming the generalizability of diagnostic or management tools that may have been developed or tested in a homogenous population. We are aware of a certain OCT platform that states a caveat: 'Classification Results valid for Caucasian eyes only.'

Overall, the results of the present study do call into question the generalizability of OCTA vessel density differences as a clinically useful tool for glaucoma diagnosis, and at face value the ganglion cell analysis performed better in the entire study population without a difference in diagnostic performance based on self-reported African vs European descent. This study does not, however, exclude the possibility that OCTA could become an equitable tool for monitoring progression or detecting early changes in POAG which would require future longitudinal studies.

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