Remote Grading of the Anterior Chamber Angle Using Goniophotographs and Optical Coherence Tomography: Implications for Telemedicine or Virtual Clinics

PURPOSE: To evaluate the agreement and accuracy of grading goniophotographs and anterior segment optical coherence tomography (AS-OCT) results for assessment of the anterior chamber angle, and elicit factors driving concordance between perceived grade and ground truth. METHODS: Three clinicians evaluated the goniophotographs and AS-OCT results of 75 patients. Graders' impressions of the angle grade, trabecular pigmentation, and iris contour were compared with the ground truth gonioscopic examination result when physically performed by a senior optometrist. Percentage agreement and kappa statistics were calculated. Binary logistic regression was used to elicit factors for accurate grading. RESULTS: Exact angle matches and binary (open or closed) evaluations were above guessing rate for all graders. There was a systematic bias toward underestimating the angle structure across all graders, especially at the superior angle, by approximately 1 ordinal unit. Kappa statistics showed fair-moderate agreement for exact (0.387–0.520) and binary (0.347–0.520) angle evaluations. Agreement was unchanged when using a multimodal approach (0.373–0.523). Factors driving concordance were primarily related to the extremes of the anterior chamber angle configuration (shallow or deep structures, and iris contour). However, prediction models did not fully explain the levels of concordance with the ground truth (maximum R(2) amongst models 0.177). CONCLUSIONS: Although moderate agreement between graders and ground truth could be obtained under binary evaluations, angle grades were generally underestimated. Factors affecting concordance were primarily the extremes of the ground truth angle and iris contour. TRANSLATIONAL RELEVANCE: We highlight factors affecting accuracy of grading goniophotography and AS-OCT images of the anterior chamber angle.