Prashant K Parekh1, James C Folk1, Priya Gupta2, Stephen R Russell3, Elliott H Sohn3, Michael D Abràmoff4. 1. Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa. 2. The Surrey Eye Care Center, Surrey, British Columbia. 3. Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa; Iowa City VA Health Care System, Iowa City, Iowa. 4. Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa; Iowa City VA Health Care System, Iowa City, Iowa; Institute for Vision Research, University of Iowa, Iowa City, Iowa; Department of Electrical and Computer Engineering, University of Iowa, Iowa City, Iowa; Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa. Electronic address: michael-abramoff@uiowa.edu.
Abstract
PURPOSE: Fundus fluorescein angiography (FFA) is the standard modality to diagnose and manage choroidal neovascularization (CNV). However, FFA is costly and has considerable morbidity from allergic reactions and a mortality of 1 per 220 000. Since the advent of anti-vascular endothelial growth factor (VEGF) therapy for CNV, OCT has been used extensively to manage CNV, but FFA is still widely used. One recent study found the sensitivity and specificity of OCT compared with FFA in diagnosis of CNV were 100% and 80.8%, respectively. We hypothesize that FFA does not affect the management of patients initially suspected of having CNV to a clinically significant degree. DESIGN: Evaluation of diagnostic test using vignettes. PARTICIPANTS: A total of 99 patients (99 eyes) who had an initial presentation of later confirmed CNV. METHODS: We retrospectively extracted in de-identified form the FFA, OCT, and clinical histories of the subjects. Vignettes were created with a standard narrative clinical history, posterior-pole color fundus image, central B-scan OCT of the initial visit, and early, mid, and late FFA of the affected eye. Four masked retinal specialists reviewed, in randomized order, these vignettes without FFA images (FFA- arm) and answered a forced choice management question: observation, 3 consecutive anti-VEGF injections, or other. After re-randomization, experts again reviewed the vignettes with the addition of the FFA images (FFA+ arm). MAIN OUTCOME MEASURES: Intraobserver and interobserver concordance and reliability statistics within and between specialists. RESULTS: Among our retina specialists, intraobserver concordances were 89.7%, 88.7%, 88.7%, and 95.9% (average 90.7%, 95% confidence interval [CI], 83.7-97.6). The average interobserver concordance for the FFA- arm was 84.0% (95% CI, 72.6-95.4), and for the FFA+ arm, 81.8% (95% CI, 68.5-95.2); paired t testing demonstrated no significant difference between the FFA- and FFA+ arms: t = 0.6, P = 0.55. CONCLUSIONS: Our data suggest a high degree of agreement in clinical decision making whether FFA was used or not. There was a similar level of agreement among specialists in the FFA- and FFA+ groups, albeit at higher, not statistically significant, variability. We believe these findings further support deferring the use of FFA in the initial management of CNV in AMD, except in treatment failures and nonstandard cases. Published by Elsevier Inc.
PURPOSE: Fundus fluorescein angiography (FFA) is the standard modality to diagnose and manage choroidal neovascularization (CNV). However, FFA is costly and has considerable morbidity from allergic reactions and a mortality of 1 per 220 000. Since the advent of anti-vascular endothelial growth factor (VEGF) therapy for CNV, OCT has been used extensively to manage CNV, but FFA is still widely used. One recent study found the sensitivity and specificity of OCT compared with FFA in diagnosis of CNV were 100% and 80.8%, respectively. We hypothesize that FFA does not affect the management of patients initially suspected of having CNV to a clinically significant degree. DESIGN: Evaluation of diagnostic test using vignettes. PARTICIPANTS: A total of 99 patients (99 eyes) who had an initial presentation of later confirmed CNV. METHODS: We retrospectively extracted in de-identified form the FFA, OCT, and clinical histories of the subjects. Vignettes were created with a standard narrative clinical history, posterior-pole color fundus image, central B-scan OCT of the initial visit, and early, mid, and late FFA of the affected eye. Four masked retinal specialists reviewed, in randomized order, these vignettes without FFA images (FFA- arm) and answered a forced choice management question: observation, 3 consecutive anti-VEGF injections, or other. After re-randomization, experts again reviewed the vignettes with the addition of the FFA images (FFA+ arm). MAIN OUTCOME MEASURES: Intraobserver and interobserver concordance and reliability statistics within and between specialists. RESULTS: Among our retina specialists, intraobserver concordances were 89.7%, 88.7%, 88.7%, and 95.9% (average 90.7%, 95% confidence interval [CI], 83.7-97.6). The average interobserver concordance for the FFA- arm was 84.0% (95% CI, 72.6-95.4), and for the FFA+ arm, 81.8% (95% CI, 68.5-95.2); paired t testing demonstrated no significant difference between the FFA- and FFA+ arms: t = 0.6, P = 0.55. CONCLUSIONS: Our data suggest a high degree of agreement in clinical decision making whether FFA was used or not. There was a similar level of agreement among specialists in the FFA- and FFA+ groups, albeit at higher, not statistically significant, variability. We believe these findings further support deferring the use of FFA in the initial management of CNV in AMD, except in treatment failures and nonstandard cases. Published by Elsevier Inc.
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