title: Assessment of change of optic nerve head cupping in pediatric glaucoma using the RetCam 120.
abstract: OBJECTIVE
  To ascertain the interobserver agreement among various specialists when analyzing images of the optic nerve head taken with the RetCam 120 (Clarity Medical Systems, Inc., Pleasanton, CA) for assessing the progression of optic disk cupping in pediatric glaucoma.
  
  
  METHODS
  Five observers compared pairs of RetCam 120 two-dimensional photographs from 64 eyes to identify whether or not changes in the optic disk had occurred. Observers included a pediatric glaucoma specialist, pediatric neurophthalmologist, strabismologist, pediatric ophthalmic imaging specialist, and pediatric ophthalmology fellow. Each was masked to the patient identity and clinical course. For each patient, the observers reviewed the photographs taken prior to therapy and at a minimum of 6 months following initiation of therapy. Interobserver variability was calculated and analysis conducted to identify influential variables.
  
  
  RESULTS
  Poor agreement was noted between the observers. No significant association was obtained between agreement level and variables affecting photographic quality: variability of contrast and illumination, exposure and magnification, image clarity, presence of fluorescein on the cornea, and pixelation of the image with poor resolution. Raters noted problems with these image variables in 75.6% of the observations. The Kappa statistic obtained was kappa = 0.29 with overall proportion of agreement of p = 0.69, suggesting a fair agreement but not a moderate agreement.
  
  
  CONCLUSIONS
  Comparison of RetCam 120 pediatric optic nerve head photographs, when performed subjectively by observers with different perspectives, and in isolation from clinical information, may not be a reliable indicator of cupping change. In addition, variations in image contrast, luminance, color, and pixelation pose significant challenges to agreement between observers. Comparison of RetCam 120 images should not be considered the sole criterion for monitoring pediatric glaucoma.
authors.affiliation: Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
authors.forename: Vasudha
authors.initials: V
authors.lastname: Erraguntla
authors.forename: Leslie D
authors.initials: LD
authors.lastname: MacKeen
authors.forename: Eshetu
authors.initials: E
authors.lastname: Atenafu
authors.forename: Derek
authors.initials: D
authors.lastname: Stephens
authors.forename: J Raymond
authors.initials: JR
authors.lastname: Buncic
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Budning
authors.forename: Alex V
authors.initials: AV
authors.lastname: Levin
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003941:Diagnostic Techniques, Ophthalmological / Q000295:instrumentation*; D005500:Follow-Up Studies; D005901:Glaucoma / Q000175:diagnosis* / Q000473:pathology; D006801:Humans; D007223:Infant; D007429:Intraocular Pressure; D015588:Observer Variation; D009898:Optic Disk / Q000473:pathology*; D009901:Optic Nerve Diseases / Q000175:diagnosis* / Q000209:etiology; D010781:Photography / Q000295:instrumentation; D012372:ROC Curve; D012720:Severity of Illness Index