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Randomized Controlled Trial
. 2024 Feb 21;108(3):349-356.
doi: 10.1136/bjo-2022-321643.

Differentiating stages of functional vision loss from glaucoma using the Disc Damage Likelihood Scale and cup:disc ratio

Heiko Philippin  1   2 , Einoti Naino Matayan  3   4 , Karin Marianne Knoll  3 , Edith Macha  3 , Sia Mbishi  3 , Andrew Makupa  3   4 , Cristóvão Daniel Matsinhe  3   5 , Isac Vasco da Gama  3   6 , Mário Jorge Monjane  3 , Joyce Awum Ncheda  3   7 , Francisco Alcides Francisco Mulobuana  3 , Elisante Muna  3 , Nelly Fopoussi Guylene  3   8 , Gus Gazzard  9   10 , Ana Patricia Marques  11 , Peter Shah  10   12 , David Macleod  13 , William Makupa  3   4 , Matthew J Burton  11   9
Affiliations
Randomized Controlled Trial

Differentiating stages of functional vision loss from glaucoma using the Disc Damage Likelihood Scale and cup:disc ratio

Heiko Philippin et al. Br J Ophthalmol. .

Abstract

Background: Glaucoma staging is critical for treatment planning but has rarely been tested in severe/end-stage disease. We compared the performance of the Disc Damage Likelihood Scale (DDLS) and cup:disc ratio (CDR) using a functional glaucoma staging system (GSS) as the reference standard.

Methods: Post hoc analysis of a randomised controlled trial at the Eye Department of Kilimanjaro Christian Medical Centre, Tanzania. Eligible participants (aged ≥18 years) with open-angle glaucoma, intraocular pressure (IOP) of >21 mm Hg, were randomised to timolol 0.5% eye drops or selective laser trabeculoplasty. Fundoscopy established vertical and horizontal CDRs and DDLS. Visual acuity and static visual fields were graded (GSS). The study used area under the receiver operating characteristic (AROC) curves and Spearman's rank correlation coefficients to compare staging systems. Logistic regression with generalised estimating equations determined risk factors of functional severe/end-stage glaucoma.

Results: 382 eyes (201 participants) were evaluated; 195 (51%) had severe or end-stage glaucoma; mean IOP was 26.7 (SD 6.9) mm Hg. DDLS yielded an AROC of 0.90 (95% CI 0.87 to 0.93), vertical cup:disc ratio (vCDR) of 0.88 (95% CI 0.85 to 0.91, p=0.048) for identifying severe/end-stage disease. Correlation coefficients comparing GSS to DDLS and vCDRs were 0.73 and 0.71, respectively. Advanced structural stages, vision impairment, higher IOP and less financial resources were risk factors of functional severe/end-stage glaucoma.

Conclusion: This study indicates that both structural staging systems can differentiate severe/end-stage glaucoma from less severe disease, with a moderate advantage of DDLS over CDR. Clinical examination of the optic disc plays an important role in addition to functional assessment when managing severe/end-stage glaucoma.

Keywords: Diagnostic tests/Investigation; Glaucoma.

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Conflict of interest statement

Competing interests: GG reports personal fees from Alcon, Allergan, Belkin, Equinox, Genentech–Roche, Glaukos, Ivantis, Reichert, Sight Sciences, and Thea; grants from Belkin, Santen and Thea; and non-financial involvement with the patient advocacy group GlaucomaUK, outside the submitted work; he is also a coinvestigator on three other major SLT trials (LIGHT, COAST and Belkin laser). All other authors declare no competing interests.

Figures

Figure 1
Figure 1
ROC curves of DDLS (solid line) and vCDR (dashed line) and the binary classifier of functional glaucoma stages: early/moderate/advanced versus severe/end stage. DDLS, Disc Damage Likelihood Scale; ROC, receiver operating characteristic; vCDR, vertical cup:disc ratio.
Figure 2
Figure 2
Comparison of the Disc Damage Likelihood Scale and vertical cup:disc ratio with (A) visual field mean deviation and (B) visual acuity (logMAR). Boxes show median, upper and lower quartiles. Whiskers represent scores outside the middle 50%. Outliers are presented as individual dots. logMAR, logarithm of the minimum angle of resolution.
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