Original article
Interobserver Agreement in Grading Activity and Site of Inflammation in Eyes of Patients with Uveitis

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Purpose

To evaluate the reproducibility of new criteria for grading the site and activity of intraocular inflammation.

Design

Cross-sectional agreement study.

Methods

Grading of 202 eyes of 101 patients with uveitis was conducted by pairs of uveitis subspecialists at three uveitis subspecialty clinics. Agreement in grading location of inflammation, anterior chamber (AC) cells, AC flare, vitreous cells (present or absent), and vitreous haze was calculated.

Results

Proposed criteria for grading the location of intraocular inflammation had moderate reproducibility (κ range, 0.49 to 0.61). Reproducibility improved (κ range, 0.61 to 0.73) when the newly proposed category of anterior and intermediate uveitis was excluded. The ranges of κ statistics for exact agreement on gradings of AC cells (range, 0.34 to 0.43) demonstrated low to moderate levels of agreement, and gradings of AC flare (range, 0.50 to 0.64), vitreous cells (range, 0.48 to 0.51), and vitreous haze (0.53) were in the moderate agreement range. However, agreement within 1 grade was outstanding for AC cells (κ range, 0.81 to 1.00) and vitreous haze (κ, 0.75). For AC flare, a distribution skewed toward low grades within 1 grade made κ statistics unstable.

Conclusions

Proposed methods for grading inflammatory activity have moderate reproducibility for exact agreement in most instances. However, agreement within 1 grade is excellent for grading of AC cells and vitreous haze. The method for grading the site of intraocular inflammation also produces moderate levels of agreement, and in our hands was improved by excluding both anterior and intermediate uveitis. Improved methods for grading AC flare and vitreous cells are needed.

Section snippets

Methods

The participating clinicians had at least eight years of experience as attending uveitis subspecialists. One clinician visited the practice of the other three participants to conduct the gradings, yielding three pairs of gradings. In advance of the study, each participant reviewed the SUN grading criteria for locus of inflammation, AC cells and flare, and vitreous cells (present vs absent) and haze. Tables describing the grading criteria were referred to during grading, as was a high-quality

Results

Paired gradings by two observers were performed on 202 eyes of 101 patients. Among these, uveitis was agreed by both graders to be absent in 43 second eyes (42.6% of second eyes). For 15 additional eyes (9.4% of eyes with uveitis), both graders agreed that the site of inflammation could not be determined based on examination, generally because of an opaque cataract.

For grading of AC cells, exact agreement was 57.0%, 51.4%, and 56.9% at the three centers, respectively (Figure 1). The

Discussion

We believe that these data constitute the first formal analysis evaluating the reproducibility of criteria proposed by an international consensus panel for grading the anatomic location of uveitis and its activity in the AC and vitreous cavity. An appropriately large sample of eyes with uveitis was graded at three different centers by uveitis experts who have participated in international clinical trials that use these gradings as study outcomes.

Although exact agreement in grading of AC cells

Dr John H. Kempen is an Associate Professor of Ophthalmology and Epidemiology at the University of Pennsylvania School of Medicine, and Director of both the Ocular Inflammation Service and Ophthalmic Epidemiology. His research centers on the effects of treatment for patients with ocular inflammatory and infectious diseases. Dr Kempen serves as Chairman of the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study and as Vice-Chairman of the Multicenter Uveitis Steroid Treatment

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Dr John H. Kempen is an Associate Professor of Ophthalmology and Epidemiology at the University of Pennsylvania School of Medicine, and Director of both the Ocular Inflammation Service and Ophthalmic Epidemiology. His research centers on the effects of treatment for patients with ocular inflammatory and infectious diseases. Dr Kempen serves as Chairman of the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study and as Vice-Chairman of the Multicenter Uveitis Steroid Treatment (MUST) Trial.

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