Diagnostic Ability of the Heidelberg Retina Tomograph 3 for Glaucoma

doi:10.1016/j.ajo.2007.09.039

American Journal of Ophthalmology

Volume 145, Issue 2, February 2008, Pages 354-359.e2

https://doi.org/10.1016/j.ajo.2007.09.039 Get rights and content

Purpose

To compare the diagnostic ability of the Heidelberg Retina Tomograph 3 (HRT3) and the Heidelberg Retina Tomograph 2 (HRT2) for discriminating between healthy eyes and eyes with glaucomatous visual field loss.

Design

Retrospective cross-sectional study.

Methods

Participants were 93 healthy subjects and 90 patients with open-angle glaucoma. All participants underwent imaging of the optic nerve head with the HRT2. Afterward, HRT data also were analyzed using version 3 of the software without modifying the optic disk contour line. The receiver operating characteristic (ROC) curves between normal and glaucomatous subjects were plotted for the global stereometric parameters of both software versions. Moorfields regression analysis (MRA) and glaucoma probability score (GPS) diagnostic abilities also were compared.

Results

The parameters with the largest areas under the ROC curve were the Frederick S. Mikelberg (FSM) discriminant function for the HRT3 (0.948) and the vertical cup-to-disk ratio (0.914) for the HRT2. At a fixed specificity of 95%, the best sensitivity was 74.4% for the Reinhard O.W. Burk (RB) discriminant function of the HRT2 and 83.3% for the FSM discriminant function of the HRT3. The best sensitivity and specificity pairs for the HRT classifications were 85.5% and 76.3%, respectively, for overall MRA2, 84.4% and 83.8%, respectively, for overall MRA3, 93.3% and 58.0%, respectively, for the global color-coded GPS, and 84.4% and 74.1%, respectively, for the global GPS numerical value.

Conclusions

At 95% fixed specificity, most HRT3 parameters exhibited at least the same sensitivity for glaucoma diagnosis as the analogous parameters for the HRT2. The diagnostic ability overall of MRA3 was similar to that of the previous version. GPS exhibited higher sensitivity and somewhat lower specificity than the MRA.

Section snippets

Subjects and Measurement Protocol

The study protocol was approved by the ethics committee of Miguel Servet University Hospital, and informed written consent was obtained from all participants.

Subjects with normal eyes were recruited from among patients referred for refraction who underwent routine examination without abnormal ocular findings, hospital staff, and relatives of patients in our hospital. Patients with glaucoma were recruited from an ongoing longitudinal follow-up study at the Miguel Servet University Hospital.

Results

The clinical characteristics of both groups included in the study are shown in Table 1. The normal group consisted of 93 eyes of 93 subjects. The mean age was 56.4 ± 9.8 years. The glaucoma group included 90 eyes of 90 patients: 71 with primary open-angle glaucoma, 15 with pseudoexfoliative glaucoma, and four with pigmentary glaucoma. The mean age ± standard deviation was 60.4 ± 9.1 years. Neither age (P = .103) nor central corneal thickness (P = .386) differed significantly between the groups,

Discussion

Assessment of optic disk morphologic features and the identification of optic disk changes are key for the diagnosis and follow-up of glaucoma. Many studies report the ability of the HRT to detect glaucomatous defects at the optic nerve head1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and its advantages for obtaining numerical values that can be analyzed and compared easily.

In the present study, disk areas were similar between the normal and glaucoma groups. This is a critical factor when

Antonio Ferreras, MD, PhD, received his medical degree from the Zaragoza University, Spain followed by eye surgery training and an ophthalmology residency at the Miguel Servet University Hospital, Zaragoza, Spain. Dr Ferreras was awarded his doctorate by the University of Zaragoza in 2003. His research interests include all aspects of glaucoma diagnosis and treatment, with a particular focus on early glaucoma diagnosis techniques.

References (30)

K. Rohrschneider et al.
Reproducibility of the optic nerve head topography with a new laser tomographic scanning device
Ophthalmology
(1994)
M. Iester et al.
The effect of optic disc size on diagnostic precision with the Heidelberg retina tomograph
Ophthalmology
(1997)
G. Wollstein et al.
Identification of early glaucoma cases with the scanning laser ophthalmoscope
Ophthalmology
(1998)
A. Heijl et al.
Test-retest variability in glaucomatous visual fields
Am J Ophthalmol
(1989)
J. Caprioli
Automated perimetry in glaucoma
Am J Ophthalmol
(1991)
Z. Burgansky-Eliash et al.
Glaucoma detection with the Heidelberg Retina Tomography 3
Ophthalmology
(2007)
R.R. Wagner et al.
Continuous versus categorical data for ROC analysis: some quantitative considerations
Acad Radiol
(2001)
P. Janknecht et al.
Optic nerve head analyzer and Heidelberg retina tomograph: accuracy and reproducibility of topographic measurements in a model eye and in volunteers
Br J Ophthalmol
(1994)
F.S. Mikelberg et al.
Ability of the Heidelberg retina tomograph to detect early glaucomatous visual field loss
J Glaucoma
(1995)
L. Brigatti et al.
Correlation of visual field with scanning confocal laser optic disc measurements in glaucoma
Arch Ophthalmol
(1995)

H. Uchida et al.

Detection of structural damage from glaucoma with confocal laser image analysis

Invest Ophthalmol Vis Sci

(1996)

R. Bathija et al.

Detection of early glaucomatous structural damage with confocal scanning laser tomography

J Glaucoma

(1998)

D.S. Kamal et al.

Detection of optic disc change with the Heidelberg retina tomograph before confirmed visual field change in ocular hypertensives converting to early glaucoma

Br J Ophthalmol

(1999)

L.M. Zangwill et al.

Discriminating between normal and glaucomatous eyes using the Heidelberg retina tomograph, GDx nerve fiber analyzer, and optical coherence tomograph

Arch Ophthalmol

(2001)

M.J. Greaney et al.

Comparison of optic nerve imaging methods to distinguish normal eyes from those with glaucoma

Invest Ophthalmol Vis Sci

(2002)

Cited by (30)

Screening for glaucoma with Moorfields regression analysis and glaucoma probability score in confocal scanning laser ophthalmoscopy
2011, Canadian Journal of Ophthalmology
Citation Excerpt :
The prevalence of glaucoma as defined by the diagnostic classification in this highly selected population was 9.5% in cases in which the probable glaucoma group was associated with the definitive glaucoma group. Many studies have explored the utility of HRT3 in glaucoma diagnosis,12-17 but few have evaluated its role in a screening population.7,18 Usually, the clinical reference standard for glaucoma correlates structural (optic nerve head) and functional (visual field) damage.
To compare the validity of Moorfields regression analysis (MRA) and glaucoma probability score (GPS) of the confocal scanning laser ophthalmoscopy (Heidelberg retina tomograph 3; HRT3) in detecting glaucomatous optic nerve damage in a screening population.
Population-based, cross-sectional study.
Subjects at high risk for development of open-angle glaucoma (OAG).
All subjects underwent confocal scanning ophthalmoscopy (Heidelberg retina tomograph; HRTII) testing, visual fields testing with frequency-doubling technology perimetry (FDT), and a standard ophthalmologic examination. All HRTII images were reprocessed with HRT3. Based on an ophthalmologic examination and FDT results, eyes were classified into 4 categories: normal, possible glaucoma, probable glaucoma, and definitive glaucoma. Main outcome measures included sensitivity and specificity of HRTII/MRA, HRT3/MRA, HRT3/GPS, and combination HRT3/MRA/GPS.
The left eyes of 221 of 291 subjects were included; 4 (1.8%) eyes were classified as definitively having glaucoma. Depending on the reference standard diagnosis as well as on the borderline test-positive definition of the HRTII-3, sensitivity and specificity varied between 36.4% and 100%. For HRTII/MRA, 88.2% to 96.5%, 54.5% to 100%, and 74.5% to 93.6%; for HRT3/MRA, 61.9% to 100% and 64.3% to 85.2%; for HRT3/GPS, 85.7% to 100%; and for combination HRT3/MRA/GPS, 73.4% to 78.2%.
In this pilot study, the MRA of the HRT3 appears to be more sensitive but less specific than the MRA in the HRTII version. The GPS, although somewhat less specific than MRA (and some discs are nonclassifiable by this technique), had greater sensitivity and as a screening method may have the additional advantage of being contour-line independent.
Dépister le glaucome avec l'analyse de régression de Moorfields (ARM) et du score de probabilité du glaucome (SPG) dans l'ophtalmoscopie confocale à balayage laser (HRT3).
Étude transversale.
Sujets à haut risque de développement du glaucome à angle ouvert (GAO).
Les sujets ont subi le HRTII, la périmétrie à doublage de fréquence (PDF) et l'examen ophtalmologique standard. Les images du HRTII ont été retraitées avec le HRT3. Sur la base des résultats de l'examen ophtalmologique et du PDF, les yeux ont été classés en 4 catégories: normaux, glaucome possible, glaucome probable, et glaucome définitif. Les mesures principales incluent la sensibilité et la spécificité du HRTII-MRA, HRT3-MRA, HRT3-GPS, et de leur combinaison HRT3-MRA-GPS.
Les yeux gauches de 221 de 291 sujets ont été inclus, dont 4 (1.8%) yeux ont été classés comme ayant un glaucome définitif. Dépendamment de la définition de la positivité limite du test du HRTII-3, la sensibilité et la spécificité varient entre 36.4% et 100%. Pour le HRTII/MRA entre 88.2% et 96.5%, entre 54.5% et 100%, et entre 74.5% et 93.6%; pour le HRT3/MRA, entre 61.9% et 100% et entre 64.3% et 85.2%; pour le HRT3-GPS entre 85.7% et 100%; et pour la combinaison HRT3-MRA-GPS, entre 73.4% et 78.2%.
Dans cette étude pilote, l'ARM du HRT3 apparait plus sensible, mais moins spécifique que l'ARM du HRTII. Le SPG, quoiqu'un peu moins spécifique que l'ARM, et que certains disques optiques soient non-classifiables, a une plus grande sensibilité et pourrait avoir un avantage additionnel comme méthode de dépistage d'être indépendant du tracé de ligne de contour.
Comparison of the Diagnostic Capability of the Heidelberg Retina Tomographs 2 and 3 for Glaucoma in the Indian Population
2010, Ophthalmology
Citation Excerpt :
In a study by De león-Ortega et al,16 consisting of a mixed population of subjects with European and African ancestry, the parameter with the highest AUC and the highest sensitivity at 95% specificity was vertical cup–disc ratio in both HRT2 (0.843%–44.9%) and HRT3 (0.854%–53.9%).16 In a similar study by Ferreras et al,15 the parameter with the highest AUC was vertical cup–disc ratio (0.914) for HRT2 and FSM discriminant function (0.948) for HRT3, and the parameter with the highest sensitivity at 95% specificity was R. Burk discriminant function (74.4%) in HRT2 and FSM discriminant function (83.3%) in HRT3. The 95% CI of the AUC of the best parameters in these 2 studies overlap with each other and with those in our study.
To compare the diagnostic capability of the Heidelberg Retina Tomograph (HRT) 2 and 3 (Heidelberg Engineering, GmBH, Dossenheim, Germany) for glaucoma in an Indian population.
Evaluation of a diagnostic technology.
Ninety-eight glaucoma subjects and 79 normal controls.
All participants underwent imaging with HRT2. Heidelberg Retina Tomograph 2 examinations were exported to HRT3 software. The stereometric parameters of HRT2 and HRT3 were compared. The diagnostic capability of Moorfields Regression Analysis (MRA) in the HRT2, HRT3 with and without ethnicity correction, and Glaucoma Probability Score (GPS) of HRT3 were compared. Analysis was done with the borderline results of MRA and GPS considered as normal to derive the most specific criteria and as abnormal to derive the least specific criteria.
Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC).
On standard automated perimetry (SAP), the mean deviation (mean±standard deviation) of the glaucoma and normal groups were −7.3±6.7 dB and −0.4±1.1 dB, respectively (P<0.001). The AUC for the individual stereometric parameters of HRT2 were similar to that of HRT3. The sensitivity and specificity (most specific criteria) were 56.1% and 96.2%, respectively, for MRA of HRT2 and 56.1% and 91.1%, respectively, for MRA of HRT3. The sensitivity and specificity (least specific criteria) were 88.8% and 88.6%, respectively, for MRA of HRT2 and 70.4% and 81%, respectively, for MRA of HRT3. By using the Indian specific normative database of HRT3, the sensitivity and specificity were 37.8% and 97.5%, respectively, for the most specific criteria, and 55.1% and 89.9%, respectively, for the least specific criteria. Sensitivity and specificity of GPS were 86.7% and 68.3%, respectively, for the most specific criteria, and 93.9% and 39.2%, respectively, for the least specific criteria.
In this cohort, the diagnostic capability of HRT2 MRA was similar to that of HRT3 MRA; ethnicity correction did not improve results; GPS was more sensitive but less specific than MRA in diagnosing glaucoma.
The authors have no proprietary or commercial interest in any materials discussed in this article.
Sensitivity and Specificity of the Heidelberg Retina Tomograph II Version 3.0 in a Population-based Study: The Tajimi Study
2009, Ophthalmology
Citation Excerpt :
Many previous studies have reported the diagnostic ability of version 3.0 of HRT in hospital-based populations. Although the results vary among the reports, a moderate sensitivity (FSM: 70%∼83%,14,15 MRA: 40%∼74%,10,12,13 GPS: 58%–71%10,12,13) and a fairly high specificity (FSM: 85%–95%,14,15 MRA: 87%–93%,10,12,13 GPS: 66%–94%10,12,13) have been reported in mainly Caucasian eyes. However, there has not been a report on HRT diagnostic ability in a population-based study, a population of subjects who represent a more realistic group when mass screening is considered.
To evaluate the sensitivity and specificity of the 3 glaucoma classification programs, the FS Mikelberg discriminant function (FSM), Moorfields Regression Analysis (MRA), and Glaucoma Probability Score (GPS) of version 3.0 of the Heidelberg Retina Tomograph (HRT) II (Heidelberg Engineering, Dossenheim, Germany), in a population-based setting for the first time.
Population-based cross-sectional study.
One randomly chosen eye of each subject without glaucoma, subject with glaucoma, and subject with suspected glaucoma with reliable HRT II measurements from the Tajimi study (2297 eyes of 2297 subjects) were included for analysis.
Glaucoma was diagnosed by the optic disc and visual field findings according to the criteria of the International Society of Geographical and Epidemiological Ophthalmology. The sensitivity and specificity of FSM, MRA, and GPS were calculated. Characteristics of erroneously diagnosed glaucoma (false-negative) eyes and factors that influenced specificity with the 3 programs were investigated.
Sensitivity and specificity of FSM, MRA, and GPS.
Sensitivity and specificity varied significantly among the 3 programs: 59.1%, 39.4%, and 65.2% (P = 0.02∼0.003, chi-square test), and 86.7%, 96.1%, and 83.0% (P<0.0001) with FMS, MRA, and GPS, respectively. MRA gave the lowest sensitivity but the highest specificity. Positive predictive values for these programs ranged between 0.10 and 0.23, whereas negative predictive values ranged between 0.98 and 0.99. False-negative eyes had significantly better visual field indexes (P<0.01∼0.002, Mann–Whitney U test) and smaller cup and larger rim parameters compared with true-positive glaucoma eyes. Older age and hyperopia were negatively correlated with the specificity of GPS but not with that of FMS and MRA. Larger disc area was significantly associated with decreased specificity of all programs.
In a population-based setting, the sensitivity of the HRT II was unsatisfactory with any of the classification programs, whereas specificity was satisfactory. A significant percentage of the glaucoma discs were labeled as normal, and eyes in the earlier stage of the disease appear to be more likely to be misdiagnosed as normal. Factors such as age, refraction, and disc area had an influence on specificity, but the degree of its influence was different for each classification program.
The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Optic disc morphology - Rethinking shape
2009, Progress in Retinal and Eye Research
Morphometrics, a branch of morphology, represents the study of size and shape components of biological form and their variation in the population. Assessment of optic disc morphology is essential in the diagnosis and management of many ophthalmic disorders. Much work has been performed to characterize size-related parameters of the optic disc; however, limited information is available on shape variation in the general population. In contrast to optic disc or cup sizes, which are conceptually meaningful variables with a defined unit of measurement, there are few metric constructs by which to quantify, visualize and interpret variation in optic disc or cup shape. This has significance in ophthalmic diseases with a genetic basis as recent evidence has suggested that optic disc shape may be heritable. Conventional optic disc shape measures of ‘ovality’ and ‘form-factor’ reduce a complex structure to a single number and eliminate information of potential diagnostic relevance from further analyses. The recent advent of ‘geometric morphometrics’, a branch of statistics that incorporates tools from geometry, biometrics and computer graphics in the quantitative analysis of biological forms, has enabled spatial relationships in shape data to be retained during analysis. The analytical methods employed in geometric morphometrics can be separated into two distinct groups: landmark-based (e.g. Procrustes analysis, thin-plate splines) and boundary outline techniques (e.g. Fourier analysis). In this review, we summarize current approaches to the study of optic disc morphology, discuss the underlying theory of geometric morphometrics within the context of analytical techniques and then explore the contemporary relevance of the subject matter to several biological fields. Finally we illustrate the potential application of geometric morphometrics to the specific problem of optic disc shape and glaucoma assessment.
Scanning laser polarimetry and confocal scanning laser ophthalmoscopy: technical notes on their use in glaucoma
2008, Progress in Brain Research
Citation Excerpt :
The technique provides stereometric data by applying an automatic model of the optic nerve head shape, and the resultant morphological parameters are analyzed by a machine-learning classifier (relevance vector machine) resulting in a glaucoma probability score (GPS). The GPS analysis provides a disease probability value based on the three-dimensional shape of the optic nerve and RNFL, and this classification represents the likelihood of glaucoma and not the level of damage; thus, higher GPS values do not necessarily indicate more advanced disease (Ferreras et al., 2008). The limits are represented by the presence of opacity of dioptric means, miotic pupils, optic nerve head abnormalities (colobomata and drusen), previous refractive surgery, and filtering surgery in the previous 6 months (Bresson-Dumont et al., 2003).
The mere intraocular pressure (IOP) measurement and the visual field (VF) examination do not allow early primary open-angle glaucoma (POAG) diagnosis. At present, the morphological and morphometric analysis of the optic disk is considered very important for an early diagnosis and follow-up of the disease. The recent introduction of laser systems equipped with new polarimetry techniques (GDx) and confocal tomography (HRT) allows an objective, quantitative, and reproducible evaluation of the morphometry and morphology of the optic disk and retinal nerve fiber layer (RNFL). The GDx, scanning laser polarimetry, studies the RNFL. The HRT, confocal scanning laser tomography, examines several optic disk and peripapillar area parameters. These devices allow obtaining objective and quantitative data concerning RNFL and optic nerve head. They represent complementary and important examinations in case of uncertain POAG diagnosis. The correct evaluation of the parameters studied by these techniques and the knowledge of the instruments’ limits are needed for an adequate interpretation of the results obtained.
Spotlight on the disc-damage likelihood scale (Ddls)
2021, Clinical Ophthalmology

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Luís E. Pablo, MD, is a Professor of Ophthalmology and Optics at Zaragoza University in Spain. He completed his residency in ophthalmology in 1994. His areas of research interest are clinical and experimental glaucoma. Currently, Dr Pablo is Vice-Secretary-General of the Spanish Glaucoma Society and practices at the Glaucoma Unit in the Department of Ophthalmology at Miguel Servet University Hospital, Zargoza, Spain.

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Original articleDiagnostic Ability of the Heidelberg Retina Tomograph 3 for Glaucoma

Purpose

Design

Methods

Results

Conclusions

Section snippets

Subjects and Measurement Protocol

Results

Discussion

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Acad Radiol

Optic nerve head analyzer and Heidelberg retina tomograph: accuracy and reproducibility of topographic measurements in a model eye and in volunteers

Br J Ophthalmol

Ability of the Heidelberg retina tomograph to detect early glaucomatous visual field loss

J Glaucoma

Correlation of visual field with scanning confocal laser optic disc measurements in glaucoma

Arch Ophthalmol

Detection of structural damage from glaucoma with confocal laser image analysis

Invest Ophthalmol Vis Sci

Detection of early glaucomatous structural damage with confocal scanning laser tomography

J Glaucoma

Detection of optic disc change with the Heidelberg retina tomograph before confirmed visual field change in ocular hypertensives converting to early glaucoma

Br J Ophthalmol

Discriminating between normal and glaucomatous eyes using the Heidelberg retina tomograph, GDx nerve fiber analyzer, and optical coherence tomograph

Arch Ophthalmol

Comparison of optic nerve imaging methods to distinguish normal eyes from those with glaucoma

Invest Ophthalmol Vis Sci

Original article
Diagnostic Ability of the Heidelberg Retina Tomograph 3 for Glaucoma