title: Agreement among clinicians in the recognition of patterns of optic disk damage in glaucoma.
abstract: OBJECTIVE
  To determine the interobserver and intraobserver agreement in the recognition of different patterns of glaucomatous optic disk damage and evaluate if these patterns changed over time in patients followed for a number of years.
  
  
  METHODS
  Patients with early to moderate glaucoma (n = 105) were consecutively enrolled to participate in a prospective observational study. In the first part of the present study, optic disk photographs obtained closest to patient's entry date in the prospective study were classified in a masked fashion by three observers according to the pattern of optic disk damage into one of the following: (1) focal, (2) myopic, (3) senile sclerotic, (4) concentric cup enlargement, (5) normal appearance, or (6) miscellaneous (those disks that did not qualify for any of the other groups). The observers were also asked to assign a confidence score for each classification, ranging from 1 (low confidence) to 5 (highest confidence). The three observers reclassified the photographs after a minimal period of 2 months, in order to assess intraobserver agreement. In a second part of the study, one observer reviewed, in a masked fashion, all the optic disk photographs that had been taken during the routine follow-up of the 105 patients in order to evaluate whether the classification of disk pattern changed over time.
  
  
  RESULTS
  Intraobserver agreement yielded kappa values (95% confidence interval [CI]) from 0.51 (CI, 0.40 to 0.62) to 0.85 (CI, 0.77 to 0.93) depending on the observer. Interobserver agreement kappa values between all three observers was 0.40 (CI, 0.35 to 0.46), but it improved if photographs classified with moderate or higher degrees of confidence were included (0.52 [CI, 0.44 to 0.60]). During a mean follow-up period of 8.2 +/- 4.8 years, 41.6% of the eyes were always classified into the same group and 23.6% of the eyes were classified at least once into two or more of the four patterns of damage (groups 1 to 4).
  
  
  CONCLUSIONS
  Intraobserver agreement on the pattern of optic disk damage was generally very good, with some variation among the observers. Interobserver agreement was reasonable and increased proportionally with the confidence in the classification. During long-term follow-up, the pattern of optic disk damage usually did not change. This type of classification can probably be used accurately in clinical practice.
authors.affiliation: Department of Ophthalmology, Dalhousie University, Halifax, Nova Scotia, Canada. nicolela@is.dal.ca
authors.forename: M T
authors.initials: MT
authors.lastname: Nicolela
authors.forename: S M
authors.initials: SM
authors.lastname: Drance
authors.forename: D C
authors.initials: DC
authors.lastname: Broadway
authors.forename: B C
authors.initials: BC
authors.lastname: Chauhan
authors.forename: T A
authors.initials: TA
authors.lastname: McCormick
authors.forename: R P
authors.initials: RP
authors.lastname: LeBlanc
mesh_terms: D005260:Female; D005500:Follow-Up Studies; D005902:Glaucoma, Open-Angle / Q000175:diagnosis*; D006801:Humans; D007429:Intraocular Pressure; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D009885:Ophthalmology / Q000706:statistics & numerical data*; D009898:Optic Disk / Q000473:pathology*; D010781:Photography; D011446:Prospective Studies; D015203:Reproducibility of Results; D014794:Visual Fields