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The Influence of Pharmacological Mydriasis on Biomicroscopic

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The Influence of Pharmacological Mydriasis on Biomicroscopic Eye (2005) 19, 1194–1199 & 2005 Nature Publishing Group All rights reserved 0950-222X/05 $30.00 www.nature.com/eye 1 1 2 CLINICAL STUDY The influence of PD O’Brien , AJ Bogdan , P Fitzpatrick and S Beatty1 pharmacological mydriasis on biomicroscopic evaluation of the glaucomatous optic nerve head Abstract Within-observer (before and after dilation) and interobserver agreement with respect to Aims To investigate whether the presence of laminar dots (j ¼ 0.41–0.69), pharmacological mydriasis influences PPA (j ¼ 0.36–0.54), and pathological cupping interobserver agreement or within-observer (j ¼ 0.46–0.68) was typically moderate to good agreement (comparing estimates made before across the two visits where the pupil was and after dilation) in the evaluation of the dilated on one occasion only, but less reliable optic nerve head (ONH) of the glaucoma for saucering, disc notching and disc margin suspect or patient. haemorrhage. Methods Monoscopic disc photographs of Conclusion Routine pharmacological the ONH were assessed by each observer on mydriasis is not essential for reproducible two separate occasions in order to establish evaluation of the ONH for patients in whom a baseline intra- and inter-observer agreement. 1 satisfactory view of the optic disc can be Department of Then the ONH of 53 eyes of 53 patients was achieved through the undilated pupil. Ophthalmology, examined by each observer on two separate Waterford Regional Eye (2005) 19, 1194–1199. doi:10.1038/sj.eye.6701734; occasions, the pupil being pharmacologically Hospital, published online 29 October 2004 Ireland dilated on only one of these visits. Each observer commented on the vertical and Keywords: cup disc ratio; glaucoma; 2Department of Public horizontal cup-to-disc (C/D) ratio, and the interobserver agreement; mydriasis Health Medicine & presence of the following ONH parameters: Epidemiology, laminar dots; disc haemorrhage; disc Introduction University College Dublin, saucering; disc notching, and peripapillary Dublin, Ireland The diagnosis and management of glaucoma atrophy (PPA). depends on evaluation of the optic nerve head Results Intersessional variability of C/D Correspondence: (ONH), thus rendering a reproducible method ratio estimates, based on photographs of the PD O’Brien, of assessing the ONH indispensable to the Department of ONH, was similar for the two observers. The ophthalmologist. In the clinical setting, slit-lamp Ophthalmology, 7 mean ( standard deviation) age of the 53 biomicroscopic estimation of the optic cup-to- Mater Misericordiae 7 Hospital, patients was 70 ( 15) years, and the disc ratio (C/D ratio) remains the most Eccles Street, male : female ratio was 28 : 25. Intraobserver frequently used method of ONH evaluation in Dublin 7, agreement of C/D ratio estimation performed glaucoma or suspected glaucoma. Newer and Ireland through a dilated pupil on one occasion and Tel: þ 353 87 269 6867; more objective techniques with excellent Fax: þ 353 180 34787. an undilated pupil on the other occasion was reproducibility, such as stereoscopic optic disc E-mail: drobrienp@ not statistically different between observers. imaging1 and confocal scanning laser eircom.net Interobserver agreement of C/D ratio estimates ophthalmoscopy,2 are not routinely employed in were not adversely affected in a statistically the typical clinical setting. Consequently, the Received: 28 May 2004 meaningful way if ONH evaluation was consistency of clinically documented C/D ratio Accepted in revised form: performed by each observer under conditions 2 September 2004 measurements, and other ONH parameters Published online: of nonmydriasis or by each observer under relevant to the glaucoma evaluation, is 29 October 2004 conditions of pharmacological mydriasis. important. Influence of pharmacological mydriasis PD O’Brien et al 1195 Several studies have aimed to examine the intra- and haemorrhage; disc saucering; disc notching (or localised inter-observer variability in the subjective estimation of thinning of the neuroretinal rim), and peripapillary the C/D ratio.3–5 Good intraobserver agreement (the atrophy (PPA). Subjects were enrolled in this study after consistency of an observer’s evaluation recorded during giving written and informed consent to participate and separate sessions) is crucial in the monitoring of the Tenets of the Declaration of Helsinki were adhered to. glaucoma in all settings, whereas interobserver Exclusion criteria comprised previous ocular surgery in agreement (the consistency of separate observers’ the study eye, and any optic disc anomaly such as a tilted evaluations) becomes important where the glaucoma or highly myopic disc. patient, or suspect, may be evaluated by a different One eye (the study eye) of each subject was randomly observer on successive visits. assigned to receive pharmacological mydriasis (1% Kirwan et al6 investigated whether pharmacological tropicamide) on either the first or the second visit. The mydriasis influenced interobserver agreement in ONH subjects were examined by both examiners on a single evaluation, and concluded that examination without occasion with mydriatic state (undilated or dilated) such pupillary dilation markedly impairs interobserver determined by randomisation and then re-examined up agreement of the C/D ratio. In that paper, each patient to 2 weeks later in the opposite mydriatic state, that is, was randomly assigned to pupillary dilatation or not, without mydriasis if mydriasis had been used before, or and then examined by both observers on a single visit. with mydriasis if that had not been used for the initial Consequently, intraobserver agreement was not assessed. examination. The same slit-lamp (Haag-Streits) and the We report the results of a study designed to investigate same indirect biomicroscopic 90 dioptre lens (nontinted, whether pharmacological mydriasis influences firstly, Volks) were used by both observers on each occasion. interobserver agreement and secondly, within-observer An independent study coordinator recorded the pupil agreement before and after pupil dilation, in the diameter using the slit-lamp on both clinic visits evaluation of the ONH in the context of the patient with (undilated and dilated), and randomly selected the study glaucoma or suspected glaucoma. eye based on the toss of a coin. One observer (SB), who was experienced in cataract grading for research purposes, graded the lens in each Materials and methods study eye under conditions of pharmacological Baseline agreement mydriasis using the Lens Opacification Cataract System (LOCSIIITM). Each observer was masked to previous The first part of this study was designed to give baseline estimates by either observer, and to the clinical details. inter- and intra-observer agreement data for two observers. In order to estimate this, both observers graded monoscopic optic disc photographs of 29 eyes on Statistical analysis two separate occasions. These photographs were taken Bland–Altman plots were generated to examine from patients sent from a general clinic for ‘baseline optic agreement between and within observers for the disc photography’. Each examiner had a minimum of estimation of the C/D ratio by plotting the difference 5 years’ experience in clinical ophthalmology. Each between the readings of two observers against mean commented on the following ONH parameters: values, or between readings for each observer under horizontal C/D ratio; vertical C/D ratio, and gave a dilated and undilated conditions against mean values, judgement on whether or not the optic disc was respectively. The F-test was used to determine whether pathologically cupped. Each observer was masked to the variances were significantly different. clinical data, his previous responses, and the responses of The unweighted kappa (k) was used to evaluate the other observer. The observers were encouraged to agreement, between and within observers, in the estimate the C/D ratio to the nearest 0.05. No grading assessment of the presence or absence of: laminar dots; aids such as graticules were used by either examiner. disc haemorrhage; disc saucering; disc notching; PPA, and glaucomatous damage. The kappa statistic is used with categorical data and expresses the agreement Influence of pharmacological mydriasis between two measures corrected for chance agreement. In the second part of the study, both observers evaluated The value of kappa ranges from À1 (complete the above parameters in 53 eyes of 53 patients on two disagreement) to 0 (chance agreement) to þ 1 (perfect occasions, the pupil being dilated for only one of these agreement). Agreement was classified according to the visits. In addition to the above parameters, the observers kappa values by which it was represented, as follows: also commented on the presence or absence of the À1.0–0.0 (poor); 0.01–0.20 (negligible); 0.21–0.40 following variables: laminar dots; disc margin (passable); 0.41–0.60 (moderate); 0.61–0.80 (good); Eye Influence of pharmacological mydriasis PD O’Brien et al 1196 0.81–1.0 (excellent). 95% Confidence intervals are (k ¼ 0.52). Interobserver agreement was moderate presented for all kappa values. Differences were for categorisation of the ONH as pathological considered to be statistically significant when the 95% (k ¼ 0.46). confidence intervals of k of the two groups of observers did not overlap. Sample size was estimated using a proportions method, and gave sufficient power to detect Influence of pharmacological mydriasis a reduction in good agreement from 90 to 65%, with an The male : female ratio for the 53 volunteers enrolled in alpha error of 5% and a beta error of 20%. To assist the study was 28 : 25, with a mean (7SD) age of 70715 comparison with previous work, a good degree of years (range 27–88 years). Two additional patients were agreement was defined as a difference of 0.1 or less for excluded from the study as their fundal view was C/D ratio estimation. The proportions achieving such insufficient to allow grading of the C/D ratio, due to the levels of agreement, between and within observers, were presence of very dense cataracts. The majority of the 2 compared using the w -test.
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