Limbal and Bulbar Hyperaemia in Normal Eyes

Abstract

Purpose: To investigate the appearance of limbal and bulbar hyperaemia in normal eyes, their relationship and the inter-observer agreement of clinical grading. Methods: The right eyes of 120 healthy, non-contact lens-wearing subjects (m = 57, f = 63, median age = 45 years, range 18-77 years) were examined by two trained observers. Limbal and bulbar hyperaemia were scored using the Cornea and Contact Lens Research Unit (CCLRU) redness grading scales interpolated into 0.1 increments. Redness of four quadrants, and overall, were assessed, and quadrant-average redness was calculated. Inter-observer agreement was assessed at the start and end of the study (20 subjects each). Results: For limbal redness, the overall (1.62 ± 0.46) (mean units ± S.D.) was not significantly different from the quadrant-average (1.61 ± 0.40) score. For bulbar redness, the overall (2.02 ± 0.49) was higher than the quadrant-average (1.82 ± 0.39) score (p < 0.0001). Significant correlations were found between bulbar and limbal quadrants (Pearson: r ‡ 0.43, p < 0.0001). Significant differences in redness were found between quadrants (p < 0.0001), with nasal and temporal redder than superior and inferior quadrants. Small effects of age and gender were found for limbal redness. The inter-observer 95% limits of agreement were similar at the start and end of the study. They were larger for overall (0.57) compared with quadrant-average (0.28) redness. Conclusions: For similar populations, a limbal redness above 2.5 or a bulbar redness above 2.6 (quadrant-average) or 3.0 (overall) may be considered abnormal. Limbal and bulbar redness were correlated. Quadrant-average scores are recommended instead of overall scores, as inter-observer agreement was better.

Assessing ocular bulbar redness: a comparison of methods

“…However, the R‐scan has significantly higher variability, being similar to the subjective grading of clinicians, suggesting that conversion to a four‐step human judgment scale introduces measurement noise. Consistent with an earlier study that examined inter‐observer agreement using the IER scale, we report moderate agreement (Fleiss’ kappa: 0.43) between different clinicians for grading bulbar redness using anterior eye images . The absolute grades of the R‐scan and those polled from clinicians with the IER were not interchangeable.…”

The relationship between clinical signs and dry eye symptoms

“…The bulbar hyperaemia median score (CCLRU 2.3) and limbal hyperaemia median scores (CCLRU 2.0) were slightly higher than published norms, but within normal confidence limits. 39,50 Median ocular staining of this cohort was at a normal level. 38,51,52 For LIPCOF, this is the first time that median scores have been reported in non-contact lens wearers (1/0/1 (temporal/nasal/Sum)), which is less than that reported in experienced soft contact lens wearers (2/0/2).…”

Grading Bulbar Redness Using Cross-Calibrated Clinical Grading Scales

“…15 There are apparent differences between the four scales regarding the number of reference images, the scale levels and range, and the conjunctival region displayed. Objective techniques have been used to quantify these differences in the scale images for various physical redness characteristics, 16 -18 and confirmed the visual impression that the reference levels of these bulbar redness grading scales are not aligned (i.e., grade 1 in one scale does not necessarily display the same degree of redness in another scale 19,20 ).…”