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PurposeWe tested the hypothesis that clinical statokinetic dissociation (SKD, defined as the difference in sensitivity to static and kinetic stimuli) at the scotoma border in retinal disease is due to individual criterion bias and that SKD can be eliminated by equating the psychophysical procedures for testing static and kinetic stimulus detection.MethodsSix subjects with glaucoma and six with retinitis pigmentosa (RP) were tested. Clinical procedures (standard automated perimetry [SAP] and manual kinetic perimetry [MKP]) were used to determine clinical SKD and the region of interest for laboratory-based testing. Two-way Method of Limits (MoL) was used to establish the isocontrast region at the scotoma border in glaucoma and RP subjects. Method of Constant Stimuli (MoCS) and a two-interval forced choice (2IFC) procedure then were used to present static or kinetic (inward or outward) stimuli at different eccentricities within the isocontrast region. The results were fitted with psychometric functions to determine threshold eccentricities.ResultsClinical SKD was found in glaucoma and RP subjects, with variable magnitude among subjects, but significantly exceeding expected typical measurement variability. The resultant psychometric functions when using MoCS and 2IFC showed equal sensitivity to static and kinetic targets, thus eliminating SKD.ConclusionsClinical SKD found using clinical techniques is due to methodologic differences and criterion bias, and is eliminated by using an equated and more objective psychophysical task, similar to normal subjects.Translational relevanceEliminating SKD using a psychophysical approach minimizing criterion bias suggests that it is not useful to distinguish between normal and diseased fields.

SIGNIFICANCE In our intermediate-tier glaucoma care clinic, we demonstrate fair to moderate agreement in gonioscopy examination between optometrists and ophthalmologists, but excellent agreement when considering open versus closed angles. We highlight the need for increased consistency in the evaluation and recording of angle status using gonioscopy. PURPOSE The consistency of gonioscopy results obtained by different clinicians is not known but is important in moving toward practice modalities such as telemedicine and collaborative care clinics. The purpose of this study was to evaluate the description and concordance of gonioscopy results among different practitioners. METHODS The medical records of 101 patients seen within a collaborative care glaucoma clinic who had undergone gonioscopic assessment by two clinicians (one optometrist and either one general ophthalmologist [n = 50] or one glaucoma specialist [n = 51]) were reviewed. The gonioscopy records were evaluated for their descriptions of deepest structure seen, trabecular pigmentation, iris configuration, and other features. These were compared between clinicians (optometrist vs. ophthalmologist) and against the final diagnosis. RESULTS Overall, 51.9 and 59.8% of angles were graded identically in terms of deepest visible structure when comparing between optometrist versus general ophthalmologist and optometrist versus glaucoma specialist, respectively. The concordance increased when considering ±1 of the grade (67.4 and 78.5%, respectively), and agreement with the final diagnosis was high (>90%). Variations in angle grading other than naming structures were observed (2.0, 30, and 3.9% for optometrist, general ophthalmologist, and glaucoma specialist, respectively). Most of the time, trabecular pigmentation or iris configuration was not described. CONCLUSIONS Fair to moderate concordance in gonioscopy was achieved between optometrists and ophthalmologists in a collaborative care clinic in which there is consistent feedback and clinical review. To move toward unified medical records and a telemedicine model, improved consistency of record keeping and angle description is required.

PurposeTo evaluate the agreement and accuracy of grading goniophotographs and anterior segment optical coherence tomography (AS-OCT) results for assessment of the anterior chamber angle, and elicit factors driving concordance between perceived grade and ground truth.MethodsThree clinicians evaluated the goniophotographs and AS-OCT results of 75 patients. Graders' impressions of the angle grade, trabecular pigmentation, and iris contour were compared with the ground truth gonioscopic examination result when physically performed by a senior optometrist. Percentage agreement and kappa statistics were calculated. Binary logistic regression was used to elicit factors for accurate grading.ResultsExact angle matches and binary (open or closed) evaluations were above guessing rate for all graders. There was a systematic bias toward underestimating the angle structure across all graders, especially at the superior angle, by approximately 1 ordinal unit. Kappa statistics showed fair-moderate agreement for exact (0.387–0.520) and binary (0.347–0.520) angle evaluations. Agreement was unchanged when using a multimodal approach (0.373–0.523). Factors driving concordance were primarily related to the extremes of the anterior chamber angle configuration (shallow or deep structures, and iris contour). However, prediction models did not fully explain the levels of concordance with the ground truth (maximum R2 amongst models 0.177).ConclusionsAlthough moderate agreement between graders and ground truth could be obtained under binary evaluations, angle grades were generally underestimated. Factors affecting concordance were primarily the extremes of the ground truth angle and iris contour.Translational RelevanceWe highlight factors affecting accuracy of grading goniophotography and AS-OCT images of the anterior chamber angle.

Glaucoma is the leading cause of irreversible blindness worldwide. As a chronic disease, glaucoma presents a significant burden to the individual, health-care provider and the health-care system. Currently, strategies for treating glaucoma are focused on lowering intraocular pressure, which is aimed at slowing or arresting disease progression over time. This is the only current accepted therapeutic strategy for glaucoma, and can be achieved using topical drugs, laser trabeculoplasty, filtration surgery or cyclodestructive techniques. The lowering of intraocular pressure has been wellsupported by numerous large-scale seminal clinical trials in primary open-angle glaucoma, in both its early and advanced stages. Although such guidance remains current, in the last 10-years, there has been a significant evolution in preferred first-line therapies in the treatment of open-angle glaucoma with a resultant shift in practice patterns, particularly early in the course of the disease. These changes reflect both from the perspective of the doctor -in titrating the most effective and least risky treatment modality -and the perspective of the patient, in consenting to a treatment that preserves vision and results in minimal negative impact on quality of life. In this review, the most recent evidence regarding treatment modalities for early primary open-angle glaucoma is presented and an updated framework for management guidance is proposed.