Fluoreskeiiniangiografialöydöksen (FAG) tulkinnan vaihtelevuus kostean silmänpohjan ikärappeuman diagnostiikassa

Tanja Laukkala

Näytön aste: C

Fluoreskeiiniangiografia (FAG) tutkimusten tulkinta kostean silmänpohjan ikärappeuman (AMD) diagnostiikassa vaihtelee tulkitsijoiden ja tulkintakertojen välillä.

The aim of this retrospective study «Zayit-Soudry S, Alfasi M, Goldstein M ym. Variabil...»1 was to determine the rate of agreement among five retina specialists in classifying various angiographic features of subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD), as evaluated on printed digital fluorescein angiogram (FA) frames, as well as determination of eligibility for photodynamic treatment (PDT) according to established guidelines. Ninety-two digital FAs of 77 patients (27 men, 50 women) demonstrating subfoveal CNV secondary to AMD were obtained from the charts of patients attending to the Retina Unit of Tel Aviv Souransky Medical Center (Tel Aviv, Israel), the patients were previously diagnosed as having CNV secondary to AMD and were evaluated independently by five retina specialists. The pattern of classic component could be classified as no classic component, minimally classic, predominantly classic, or classic only. Each grader was asked to determine eligibility of each case to PDT according to established treatment guidelines, national health insurance guidelines, and one's own personal judgment. The kappa coefficient of concordance calculated for all five observers regarding CNV localization was 0.285, indicating fair overall agreement, and was 0.295, indicating fair agreement, regarding classification of leakage pattern. The kappa coefficient of agreement calculated for all five graders regarding eligibility for treatment according to established international guidelines, national health insurance, and each grader's own personal judgment was 0.163, 0.33, and 0.164, respectively, indicating slight to fair overall agreement. The authors concluded that considerable variability may exist among retina specialists interpreting FAs and should be considered in the assessment of treatment guidelines.

  • Tutkimuksen laatu: heikko
  • Sovellettavuus suomalaiseen väestöön: hyvä

Kommentti: Artikkelissa ei käsitelty kuvat tulkinneiden silmälääkäreiden kokemusta kuvien tulkinnassa, vaan viiden silmälääkärin arvioiden yhtenevyyttä.

The aim of the study «Muni RH, Altaweel M, Tennant M ym. Agreement among...»2 was to determine inter- and intraobserver agreement among Canadian retina specialists in their angiographic classification of choroidal neovascularization and their decision to treat with photodynamic therapy. Agreement was also determined between retina specialists and a Reading Center. All retina specialists in Canada were asked to participate in a web-based survey, which consisted of 24 randomly selected cases of exudative AMD provided by the University of Wisconsin Fundus Photograph Reading Center. Forty retina specialists graded 24 cases of exudative age-related macular degeneration on two occasions separated by 6 months. Participants were asked to categorize the choroidal neovascularization and indicate if they would treat with photodynamic therapy. Agreement was determined for decision to treat and for interpretation of the fluorescein angiogram. Angiographic interpretation by participants was compared with that of the Reading Center.

The 40 retina specialists have been in practice for an average of 11.9 years with a SD of 9.1 year and have been treating patients with PDT for an average of 3.6 years (SD 1.9). They consisted of 27 surgical retina specialists, 9 medical retina specialists, and 4 retina fellows. The 24 cases selected by the reading center consisted of 9 predominantly classical lesions (PC), 5 minimally classic (MC), 6 occult with no classic (ONC) and 4 others (O). The response rate for treatment decision was 915/960 (95.3%) and 951/960 for lesion categorization (99.1%).

The kappas among the 40 participants for lesion categorization and treatment decision were 0.43 (95% confidence interval: 0.36–0.52) and 0.29 (95% confidence interval: 0.18–0.42), respectively. The kappa for intraobserver agreement was 0.57 (95% confidence interval: 0.50–0.64) for lesion categorization and 0.58 (95% confidence interval: 0.43–0.74) for treatment decision. The mean percent agreement with the Reading Center for lesion categorization was 65.4%. The authors concluded that there was moderate interobserver agreement for choroidal neovascularization categorization and poor agreement among Canadian retina specialists for decision to treat with photodynamic therapy. There was moderate intraobserver agreement for both treatment decision and lesion categorization. There was moderate agreement between observers and the Reading Center for angiographic choroidal neovascularization categorization.

  • Tutkimuksen laatu: heikko
  • Sovellettavuus suomalaiseen väestöön: hyvä

Kommentti: Vaikka artikkelissa oli kartoitettu taustakokemus, sen merkitystä tulkintojen osuvuudessa ei raportoitu.

The aim of the study «Holz FG, Jorzik J, Schutt F ym. Agreement among op...»3 was to determine intraobserver and interobserver variation for classifying types of choroidal neovascularizations (CNV) in exudative age-related macular degeneration (ARMD). Digital high-quality fluorescein angiograms of 40 patients with neovascular ARMD were evaluated independently by 16 retinal specialists who were members of the European Fluorescein Angiography Club during a meeting in France in December 2000.

Fluorescein angiographies were presented in two randomized sequences (series A and B) to each masked reader for classification of type of CNV into classic, occult, or mixed with classic component of less or greater 50%. Agreement was evaluated by calculating kappa statistics (kappa) and intraclass correlation coefficients.

The mean kappa coefficient was 0.64 +/- 0.11 for intraobserver variation, with a range from 0.44 to 0.89. For interobserver variation the intraclass correlation coefficients was calculated as 0.66 (95% confidence interval [CI] 0.56, 0.77) for series A and as 0.55 (95% CI 0.43, 0.67) for series B.

The authors conclude that angiographic classification of CNV secondary to ARMD can vary considerably not only between observers but also for repeated evaluation by the same observer. Because various current and emerging treatments including photodynamic therapy are based on specific angiographic characteristics, accurate interpretation was emphasized.

  • Tutkimuksen laatu: heikko
  • Sovellettavuus suomalaiseen väestöön: hyvä

Kommentti: Osallistujien taustatyökokemusta ei tarkemmin selvitetty.

To determine interobserver agreement for classifying choroidal neovascular membranes in age-related macular degeneration «Friedman SM, Margo CE. Choroidal neovascular membr...»4 Six fluorescein angiograms of choroidal neovascular membranes were interpreted by 21 retina specialists who had been in practice for an average of 8.25 years (median 7 years, range 1.5–20 years) and were ophthalmologists with fellowship training in retinal disease. Reliability was measured by percent agreement and kappa coefficient. Interobserver agreement of membrane types ranged from perfect concordance for a small, classic membrane to near-random classification for a complex pattern. Mean kappa coefficient was.64. Interobserver agreement of membrane size was most variable for intermediate size lesions (mean kappa coefficient = 0.40). The authors concluded that fluorescein angiographic interpretation of choroidal neovascular membrane type and size can vary considerably. Interobserver agreement was better for membrane type than for membrane size.

Kommentti: Vaikka artikkelissa oli kartoitettu työvuodet, niiden merkitystä tulkintojen osuvuudessa ei raportoitu.


  1. Zayit-Soudry S, Alfasi M, Goldstein M ym. Variability among retina specialists in evaluating fluorescein angiograms of patients with neovascular age-related macular degeneration. Retina 2007;27:798-803 «PMID: 17621192»PubMed
  2. Muni RH, Altaweel M, Tennant M ym. Agreement among Canadian retina specialists in the determination of treatment eligibility for photodynamic therapy in age-related macular degeneration. Retina 2008;28:1421-6 «PMID: 18667952»PubMed
  3. Holz FG, Jorzik J, Schutt F ym. Agreement among ophthalmologists in evaluating fluorescein angiograms in patients with neovascular age-related macular degeneration for photodynamic therapy eligibility (FLAP-study). Ophthalmology 2003;110:400-5 «PMID: 12578787»PubMed
  4. Friedman SM, Margo CE. Choroidal neovascular membranes: reproducibility of angiographic interpretation. Am J Ophthalmol 2000;130:839-41 «PMID: 11124312»PubMed