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Editors Selection IGR 7-3

Clinical examination methods: Presence of damage and predictive value

Comment by Stefano Miglior on:

13095 Baseline topographic optic disc measurements are associated with the development of primary open-angle glaucoma: the Confocal Scanning Laser Ophthalmoscopy Ancillary Study to the Ocular Hypertension Treatment Study, Zangwill LM; Weinreb RN; Beiser JA et al., Archives of Ophthalmology, 2005; 123: 1188-1197

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The paper by Zangwill et al. (803), 'Baseline topographic optic disc measurements are associated with the development of primary open angle glaucoma', is the first publication reporting the predictive value of the optic disc examination performed by means of the Confocal Scanning Laser Ophthalmoscopy (HRT I) for the development of POAG in a population with ocular hypertension. The study is highly valuable for the following reasons. 1) It provides data from a prospectively and not retrospectively planned clinical trial; 2) It reports data from a large population of 438 individuals affected by ocular hypertension followed up for more than six years; 3) It provides information based on longitudinal assessment, thus on incident cases of POAG, which implies that the CSLO classification actually preceded the development of POAG. The study shows that optic disc assessment by CSLO may be useful to detect higher risk patients for POAG, but, from the strict clinical point of view, these results have to be taken with caution. In fact the HRT discriminant function, which classifies the optic disc as being within or out normal limits, has been shown to have a low sensitivity and specificity, and the Moorfields' Regression Analysis, which classifies the optic disc as being within or out normal limits, has also been shown to have a low sensitivity but a high specificity. It should be stressed, however, that sensitivity and specificity here refer to the ability in detecting future cases of abnormality or normality and these estimates cannot be compared with the figures reported in cross-sectional studies. These data need to be confirmed, as stated by the Authors. Nonetheless, they are extremely interesting as they seem to indicate that optic disc assessment and classification by CSLO may be more accurate than optic disc assessment and classification performed by expert clinicians. This issue is of great importance as it raises the question whether instruments such as HRT, or GDx and OCT may actually be clinically useful in the detection of high risk patients for POAG. The first answer given by this manuscript tends to be yes.

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