Optimising subjective anterior eye grading precision

Abstract

To establish the optimum grading increment which ensured parity between practitioners while maximising clinical precision.Methods: Second year optometry students (n=127, 19.5 ± 1.4 years, 55% female) and qualified eye care practitioners (n=61, 40.2 ±14.8 years, 52% female) had 30 seconds to grade each of bulbar, limbal and palpebral hyperaemia of the upper lid of 4 patients imaged live with a digital slit lamp under 16x magnification, diffuse illumination, with the image projected on a screen. The patients were presented in a randomised sequence 3 times in succession, during which the graders used the Efron printed grading scale once to 0.1 precision, once to 0.5 precision and once to the nearest integer grade in a randomised order. Graders were masked to their previous responses.Results: For most grading conditions less than 20% of clinicians showed a ≤0.1 difference in grade from the mean. In contrast, more than 50% of the student graders and 40% of experienced graders showed a difference in grade from the mean within 0.5 for all conditions under measurement.Student precision in grading was better with both 0.1 and 0.5 grading precision than grading to the nearest unit, except for limbal hyperaemia where they performed more accurately with 0.5 unit precision grading. Limbal grading precision was not affected by grading step precision for experienced practitioners, but 0.1 and 0.5 grading precision were both better than 1.0 grading precision for bulbar hyperaemia and 0.1 grading precision was better than 0.5 grading precision and both were better than 1.0 grading precision for palpebral hyperaemia. Conclusion:Although narrower intervals scales maximise the ability to detect smaller clinical changes, the grading increment should not exceed one standard deviation of the discrepancy between measurements. Therefore, 0.5 grading increments are recommended for subjective anterior eye physiology grading (limbal, bulbar and palpebral redness).

2022 Glenn A. Fry Award lecture: Enhancing clinical assessment for improved ophthalmic management

“…I have played a mentoring role to support academics in the British and Irish University and College Committee of Contact Lens Educators (BUCCLE) to review the evidence base for key areas of clinical contact lens practice 124,223 and conducted studies to address gaps such as the lack of adaptation time required after fitting neophytes 224,225 (which has now been replicated by another group) 226 and optimizing the grading of ocular physiology 130 . To consolidate the increasing evidence base in contact lenses, I brought together experts in the field to create the Contact Lens Evidence–based Academic Reports, published in 2023; this was an initiative to support clinicians in performing evidence-based practice to the benefit of their patients, to identify gaps in the literature for researchers to tackle, and to identify opportunities for industry to innovate 227–233 .…”

Patient experience and physiological response to two commercially available daily disposable myopia control contact lenses

“…[21] Whilst there were small hyperaemic changes noted in the present study, the increases from baseline did not exceed 0.3 Efron grade, which is close to the level of inter-observer agreement for this parameter. [22] As these measurements were not taken beyond 6 hours of wear, it was not possible to extrapolate physiological response to longer wearing times, or to relate this to the reduction in subjective comfort reported by participants after 10 hours of wear.…”

BCLA CLEAR - Evidence-based contact lens practice

“…While it is suggested that clinical action is needed for grades >2, this depends on the feature being observed and associated signs and symptoms. In theory ECPs should use these images to interpolate to 0.1 grade increments to enhance sensitivity [145]; however in practice 0.5 steps appear to the most appropriate grade increment [146]. Digital presentation of grading scales allow image morphing between grades, but this does not seem to improve grading variability [147].…”