Limbal ischemia: Reliability of clinical assessment and implications in the management of ocular burns

Abstract

Purpose:Limbal ischemia is an important prognostic factor in the management of ocular burns. In this study, we evaluated the reliability of clinically assessing limbal ischemia among ophthalmic professionals.Methods:This study included 111 ophthalmic professionals who were shown 12 diffuse illumination color slit-lamp photographs of eyes with recent chemical injuries. Respondents were asked whether the photos were assessable and if yes, then to indicate the presence, location, and grade of limbal ischemia in each case. The responses were collected using a standard data collection sheet and the inter-observer agreement was calculated.Results:All participants responded to every question. Of the 1,332 responses, images were deemed assessable in 1,222 (91.7%) instances. The overall agreement (Fleiss’ kappa) for the presence of limbal ischemia and severity of limbal ischemia was 0.106 and 0.139, respectively (P < 0.012). Among the four groups of observers, practicing cornea specialists displayed significantly (P < 0.003) higher kappa values (0.201–0.203) when compared to residents (0.131–0.185), fellows (0.086–0.127), and optometrists (0.077–0.102). All indicated a poor level of inter-rater consistency.Conclusion:The results indicate that clinical assessment of limbal ischemia is highly subjective and there is lack of reliability even among cornea specialists who regularly manage patients with ocular burns. A non-invasive, standardized, objective, accurate, and reliable modality for ocular surface angiography is desperately needed for proper assessment and prognostication of ocular burns.

Role of anterior segment optical coherence tomography angiography in the assessment of acute chemical ocular injury: a pilot animal model study

“…The assessment of the corneal limbus in chemical ocular injury is an important surrogate to estimate the damage to the cornea limbal stem cells 35 . The two most commonly utilized classifications by Dua et al 3 and Roper-Hall 4 , incorporate clinical assessment of the extent of staining and limbal ischemia respectively post-injury using slit-lamp examination, which have been shown to be highly subjective 9 . As both classification systems have yet to be validated for use in animal models, we analyzed the strength of correlatability between the number of quadrants injured (instead of grade of injury) with the sum of mean VD from each quadrant of the corresponding eye.…”

“…Existing clinical grading systems include the extent of limbal ischemia (disruption and loss of limbal vascular arcade architecture), which may be associated with limbal stem cell loss and subsequent corneal scarring 3 – 5 . Clinical assessment of limbal ischemia on slit-lamp examination is however highly subjective 6 – 9 .…”

Persistent loss of marginal corneal arcades after chemical injury

“…Clinical assessment of limbal ischemia after chemical injury is challenging and studies have demonstrated low clinical agreement and inter-observer consistency. [ 1 ] FA and ICGA are useful tools in identifying, quantifying, and monitoring the MCA and limbal vasculature. [ 2 4 5 ] Our case of chemical injury highlights the limits of clinical color photography in detecting these vascular abnormalities.…”

“…Chemical injury to the ocular surface is an ophthalmic emergency that may result in damage to the marginal corneal arcades (MCA), limbal microvasculature, and limbal epithelial stem cell niche. [ 1 2 3 ] Accurate evaluation and monitoring of this microvasculature is essential for prognosis and management, if assessed at the slit lamp it can be challenging. [ 1 2 ] Fluorescein and indocyanine green angiography (FA and ICGA), and to a lesser extent optical coherence tomography angiography (OCTA), have been shown to be informative in the diagnosis of these vascular changes.…”

“…[ 1 2 3 ] Accurate evaluation and monitoring of this microvasculature is essential for prognosis and management, if assessed at the slit lamp it can be challenging. [ 1 2 ] Fluorescein and indocyanine green angiography (FA and ICGA), and to a lesser extent optical coherence tomography angiography (OCTA), have been shown to be informative in the diagnosis of these vascular changes. [ 4 5 6 ]…”