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Editors Selection IGR 23-4

Posterior Segment Imaging: Subjective disc assessment versus GDx and HRT

Comment by Christopher Girkin on:

26133 Clinical assessment of stereoscopic optic disc photographs for glaucoma: the European Optic Disc Assessment Trial, Reus NJ; Lemij HG; Garway-Heath DF et al., Ophthalmology, 2010; 117: 717-723

See also comment(s) by Paul Healey •

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In their recent paper, Reus et al. (699) compared the diagnostic accuracy of subjective assessment of stereo disc photo performed by a large sample of ophthalmologist across Europe to the diagnostic accuracy of the GDx and HRT. Most of the prior literature demonstrates that the GDx and HRT perform similarly to expert optic nerve assessment, with some studies showing slightly better performance with imaging and others with better performance with subjective evaluation. However, the prior literature usually compares imaging test against a handful of fellowship trained glaucoma specialists, often with extensive experience in optic nerve examination and involved in imaging research. This may not reflect the diagnostic acumen of general ophthalmologists who care for the bulk of these patients with early disease or those who are suspicious for the disease.

Subjective disc evaluation by ophthalmologists can be improved; more recent residency graduates performed better

The range of diagnostic accuracy among the 243 ophthalmologists from 11 European countries ranged from 61.4% to 94.3%. The diagnostic accuracy of the GDx NFI (93.2%) and the HRT (89.9%) was superior to the average accuracy obtained from ophthalmologist photo assessment (80.5%). The findings of the study have significant implications in deciding how best to implement imaging devices within a health care delivery model to detect disease. Given the numerous studies that demonstrate a poor rate of documentation of the optic nerve in clinical practice and the growing demands of an already stressed healthcare system in developed countries, it is a critically important finding that rapid, automated, easy to use, readily available devices perform better than the average general ophthalmologist at disease detection. Additionally, the study also suggests that subjective disc evaluation by ophthalmologists can be improved since variations where seen across countries (the UK ophthalmologist performed significantly better than the rest of Europe) and that more recent residency graduates performed better than individuals out farther from training.

Particular training methods delivered in a continue education program could enhance clinical performance

These variations in the time from and location of training suggest that particular training methods delivered in a continue education program could enhance clinical performance. Other interesting factors not assessed by the paper, that may be the subject of future work would be variation in diagnostic performance with the devices and subjectively with ocular characteristics like disease severity, disc area, and particular phenotypes of disease.

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