Variability and effect sizes of intracranial current source density estimations during pain: Systematic review, experimental findings, and future perspectives.

Pain arises from the integration of sensory and cognitive processes in the brain, resulting in specific patterns of neural oscillations that can be characterized by measuring electrical brain activity. Current source density (CSD) estimation from low-resolution brain electromagnetic tomography (LORETA) and its standardized (sLORETA) and exact (eLORETA) variants, is a common approach to identify the spatiotemporal dynamics of the brain sources in physiological and pathological pain-related conditions. However, there is no consensus on the magnitude and variability of clinically or experimentally relevant effects for CSD estimations. Here, we systematically examined reports of sample size calculations and effect size estimations in all studies that included the keywords pain, and LORETA, sLORETA, or eLORETA in Scopus and PubMed. We also assessed the reliability of LORETA CSD estimations during non-painful and painful conditions to estimate hypothetical sample sizes for future experiments using CSD estimations. We found that none of the studies included in the systematic review reported sample size calculations, and less than 20% reported measures of central tendency and dispersion, which are necessary to estimate effect sizes. Based on these data and our experimental results, we determined that sample sizes commonly used in pain studies using CSD estimations are suitable to detect medium and large effect sizes in crossover designs and only large effects in parallel designs. These results provide a comprehensive summary of the effect sizes observed using LORETA in pain research, and this information can be used by clinicians and researchers to improve settings and designs of future pain studies.

Feasibility of imaging evoked activity throughout the rat brain using electrical impedance tomography.

Electrical Impedance Tomography (EIT) is an emerging technique which has been used to image evoked activity during whisker displacement in the cortex of an anaesthetised rat with a spatiotemporal resolution of 200 µm and 2 ms. The aim of this work was to extend EIT to image not only from the cortex but also from deeper structures active in somatosensory processing, specifically the ventral posterolateral (VPL) nucleus of the thalamus. The direct response in the cortex and VPL following 2 Hz forepaw stimulation were quantified using a 57-channel epicortical electrode array and a 16-channel depth electrode. Impedance changes of -0.16 ±â€¯0.08% at 12.9 ±â€¯1.4 ms and -0.41 ±â€¯0.14% at 8.8±1.9 ms were recorded from the cortex and VPL respectively. For imaging purposes, two 57-channel epicortical electrode arrays were used with one placed on each hemisphere of the rat brain. Despite using parameters optimised toward measuring thalamic activity and undertaking extensive averaging, reconstructed activity was constrained to the cortical somatosensory forepaw region and no significant activity at a depth greater than 1.6 mm below the surface of the cortex could be reconstructed. An evaluation of the depth sensitivity of EIT was investigated in simulations using estimates of the conductivity change and noise levels derived from experiments. These indicate that EIT imaging with epicortical electrodes is limited to activity occurring 2.5 mm below the surface of the cortex. This depth includes the hippocampus and so EIT has the potential to image activity, such as epilepsy, originating from this structure. To image deeper activity, however, alternative methods such as the additional implementation of depth electrodes will be required to gain the necessary depth resolution.

Regional expiratory time constants in severe respiratory failure estimated by electrical impedance tomography: a feasibility study.

BACKGROUND: Electrical impedance tomography (EIT) has been used to guide mechanical ventilation in ICU patients with lung collapse. Its use in patients with obstructive pulmonary diseases has been rare since obstructions could not be monitored on a regional level at the bedside. The current study therefore determines breath-by-breath regional expiratory time constants in intubated patients with chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS). METHODS: Expiratory time constants calculated from the global impedance EIT signal were compared to the pneumatic volume signals measured with an electronic pneumotachograph. EIT-derived expiratory time constants were additionally determined on a regional and pixelwise level. However, regional EIT signals on a single pixel level could in principle not be compared with similar pneumatic changes since these measurements cannot be obtained in patients. For this study, EIT measurements were conducted in 14 intubated patients (mean Simplified Acute Physiology Score II (SAPS II) 35 ± 10, mean time on invasive mechanical ventilation 36 ± 26 days) under four different positive end-expiratory pressure (PEEP) levels ranging from 10 to 17 cmH2O. Only patients with moderate-severe ARDS or COPD exacerbation were included into the study, preferentally within the first days following intubation. RESULTS: Spearman's correlation coefficient for comparison between EIT-derived time constants and those from flow/volume curves was between 0.78 for tau (τ) calculated from the global impedance signal up to 0.83 for the mean of all pixelwise calculated regional impedance changes over the entire PEEP range. Furthermore, Bland-Altman analysis revealed a corresponding bias of 0.02 and 0.14 s within the limits of agreement ranging from - 0.50 to 0.65 s for the aforementioned calculation methods. In addition, exemplarily in patients with moderate-severe ARDS or COPD exacerbation, different PEEP levels were shown to have an influence on the distribution pattern of regional time constants. CONCLUSIONS: EIT-based determination of breath-by-breath regional expiratory time constants is technically feasible, reliable and valid in invasively ventilated patients with severe respiratory failure and provides a promising tool to individually adjust mechanical ventilation in response to the patterns of regional airflow obstruction. TRIAL REGISTRATION: German Trial Register DRKS 00011650 , registered 01/31/17.

Detection of 'best' positive end-expiratory pressure derived from electrical impedance tomography parameters during a decremental positive end-expiratory pressure trial.

INTRODUCTION: This study compares different parameters derived from electrical impedance tomography (EIT) data to define 'best' positive end-expiratory pressure (PEEP) during a decremental PEEP trial in mechanically-ventilated patients. 'Best' PEEP is regarded as minimal lung collapse and overdistention in order to prevent ventilator-induced lung injury. METHODS: A decremental PEEP trial (from 15 to 0 cm H2O PEEP in 4 steps) was performed in 12 post-cardiac surgery patients on the ICU. At each PEEP step, EIT measurements were performed and from this data the following were calculated: tidal impedance variation (TIV), regional compliance, ventilation surface area (VSA), center of ventilation (COV), regional ventilation delay (RVD index), global inhomogeneity (GI index), and intratidal gas distribution. From the latter parameter we developed the ITV index as a new homogeneity parameter. The EIT parameters were compared with dynamic compliance and the PaO2/FiO2 ratio. RESULTS: Dynamic compliance and the PaO2/FiO2 ratio had the highest value at 10 and 15 cm H2O PEEP, respectively. TIV, regional compliance and VSA had a maximum value at 5 cm H2O PEEP for the non-dependent lung region and a maximal value at 15 cm H2O PEEP for the dependent lung region. GI index showed the lowest value at 10 cm H2O PEEP, whereas for COV and the RVD index this was at 15 cm H2O PEEP. The intratidal gas distribution showed an equal contribution of both lung regions at a specific PEEP level in each patient. CONCLUSION: In post-cardiac surgery patients, the ITV index was comparable with dynamic compliance to indicate 'best' PEEP. The ITV index can visualize the PEEP level at which ventilation of the non-dependent region is diminished, indicating overdistention. Additional studies should test whether application of this specific PEEP level leads to better outcome and also confirm these results in patients with acute respiratory distress syndrome.

Effects of sitting position on ventilation distribution determined by electrical impedance tomography in ventilated ARDS patients.

OBJECTIVE: The study aimed to evaluate the improvements in pulmonary ventilation following a sitting position in ventilated ARDS patients using electrical impedance tomography. METHODOLOGY: A total of 17 patients with ARDS under mechanical ventilation participated in this study, including 8 with moderate ARDS and 9 with severe ARDS. Each patient was initially placed in the supine position (S1), transitioned to sitting position (SP) for 30 min, and then returned to the supine position (S2). Patients were monitored for each period, with parameters recorded. MAIN OUTCOME MEASURES: The primary outcome included the spatial distribution parameters of EIT, regional of interest (ROI), end-expiratory lung impedance (ΔEELI), and parameters of respiratory mechanics. RESULTS: Compared to S1, the SP significantly altered the distribution in ROI1 (11.29 ± 4.70 vs 14.88 ± 5.00 %, p = 0.003) and ROI2 (35.59 ± 8.99 vs 44.65 ± 6.97 %, p ＜ 0.001), showing reductions, while ROI3 (39.71 ± 11.49 vs 33.06 ± 6.34 %, p = 0.009), ROI4 (13.35 ± 8.76 vs 7.24 ± 5.23 %, p ＜ 0.001), along with peak inspiratory pressure (29.24 ± 3.96 vs 27.71 ± 4.00 cmH2O, p = 0.036), showed increases. ΔEELI decreased significantly ventrally (168.3 (40.33 - 189.5), p ＜ 0.0001) and increased significantly dorsally (461.7 (297.5 - 683.7), p ＜ 0.0001). The PaO2/FiO2 ratio saw significant improvement in S2 compared to S1 after 30 min in the seated position (108 (73 - 130) vs 96 (57 - 129) mmHg, p = 0.03). CONCLUSIONS: The sitting position is associated with enhanced compliance, improved oxygenation, and more homogenous ventilation in patients with ventilated ARDS compared to the supine position. IMPLICATIONS FOR CLINICAL PRACTICE: It is important to know the impact of postural changes on patient pulmonary ventilation in order to standardize safe practices in critically ill patients. It may be helpful in the management among ventilated patients.

Artificial Intelligence in Multiphoton Tomography: Atopic Dermatitis Diagnosis.

The diagnostic possibilities of multiphoton tomography (MPT) in dermatology have already been demonstrated. Nevertheless, the analysis of MPT data is still time-consuming and operator dependent. We propose a fully automatic approach based on convolutional neural networks (CNNs) to fully realize the potential of MPT. In total, 3,663 MPT images combining both morphological and metabolic information were acquired from atopic dermatitis (AD) patients and healthy volunteers. These were used to train and tune CNNs to detect the presence of living cells, and if so, to diagnose AD, independently of imaged layer or position. The proposed algorithm correctly diagnosed AD in 97.0 ± 0.2% of all images presenting living cells. The diagnosis was obtained with a sensitivity of 0.966 ± 0.003, specificity of 0.977 ± 0.003 and F-score of 0.964 ± 0.002. Relevance propagation by deep Taylor decomposition was used to enhance the algorithm's interpretability. Obtained heatmaps show what aspects of the images are important for a given classification. We showed that MPT imaging can be combined with artificial intelligence to successfully diagnose AD. The proposed approach serves as a framework for the automatic diagnosis of skin disorders using MPT.

Intravenous administration of normal saline may be misinterpreted as a change of end-expiratory lung volume when using electrical impedance tomography.

Electrical impedance tomography (EIT) is a noninvasive imaging modality that allows real-time monitoring of regional lung ventilation. The aim of the study is to investigate whether fast saline infusion causes changes in lung impedance that could affect the interpretation of EIT data. Eleven pigs were anaesthetized and mechanically ventilated. A bolus of 500 mL of normal saline was administered rapidly. Two PEEP steps were performed to allow quantification of the effect of normal saline on lung impedance. The mean change of end-expiratory lung impedance (EELI) caused by the saline bolus was equivalent to a virtual decrease of end-expiratory lung volume (EELV) by 227 (188-250) mL and decremental PEEP step of 4.40 (3.95-4.59) cmH2O (median and interquartile range). In contrast to the changes of PEEP, the administration of normal saline did not cause any significant differences in measured EELV, regional distribution of lung ventilation determined by EIT or in extravascular lung water and intrathoracic blood volume. In conclusion, EELI can be affected by the changes of EELV as well as by the administration of normal saline. These two phenomena can be distinguished by analysis of regional distribution of lung ventilation.

Comparison of electrical impedance tomography and intracranial pressure during dehydration treatment of cerebral edema.

Cerebral edema after brain injury can lead to brain damage and death if diagnosis and treatment are delayed. This study investigates the feasibility of employing electrical impedance tomography (EIT) as a non-invasive imaging tool for monitoring the development of cerebral edema, in which impedance imaging of the brain related to brain water content is compared with intracranial pressure (ICP). We enrolled forty patients with cerebral hemorrhage who underwent lateral external ventricular drain with intraventricular ICP and EIT monitoring for 3 h after initiation of dehydration treatment. The average reconstructed impedance value (ARV) calculated from EIT images was compared with ICP. Dehydration effects induced changes in ARV and ICP showed a close negative correlation in all patients, and the mean correlation reached R2 = 0.78 ±â€¯0.16 (p < .001). A regression equation (R2 = 0.62, p < .001) was formulated from the total of measurement data. The 95% limits of agreement were - 6.13 to 6.13 mmHg. Adaptive clustering and variance analysis of normalized changes in ARV and ICP showed 92.5% similarity and no statistically significant differences (p > .05). Moreover, the sensitivity, specificity and area under the curve of changes in ICP >10 mmHg were 0.65, 0.73 and 0.70 respectively. The findings show that EIT can monitor changes in brain water content associated with cerebral edema, which could provide a real-time and non-invasive imaging tool for early identification of cerebral edema and the evaluation of mannitol dehydration.

The effects of chiropractic spinal manipulation on central processing of tonic pain - a pilot study using standardized low-resolution brain electromagnetic tomography (sLORETA).

The objectives of the study were to investigate changes in pain perception and neural activity during tonic pain due to altered sensory input from the spine following chiropractic spinal adjustments. Fifteen participants with subclinical pain (recurrent spinal dysfunction such as mild pain, ache or stiffness but with no pain on the day of the experiment) participated in this randomized cross-over study involving a chiropractic spinal adjustment and a sham session, separated by 4.0 ± 4.2 days. Before and after each intervention, 61-channel electroencephalography (EEG) was recorded at rest and during 80 seconds of tonic pain evoked by the cold-pressor test (left hand immersed in 2 °C water). Participants rated the pain and unpleasantness to the cold-pressor test on two separate numerical rating scales. To study brain sources, sLORETA was performed on four EEG frequency bands: delta (1-4 Hz), theta (4-8 Hz), alpha (8-12 Hz) and beta (12-32 Hz). The pain scores decreased by 9% after the sham intervention (p < 0.05), whereas the unpleasantness scores decreased by 7% after both interventions (p < 0.05). sLORETA showed decreased brain activity following tonic pain in all frequency bands after the sham intervention, whereas no change in activity was seen after the chiropractic spinal adjustment session. This study showed habituation to pain following the sham intervention, with no habituation occurring following the chiropractic intervention. This suggests that the chiropractic spinal adjustments may alter central processing of pain and unpleasantness.

Electrode fabrication and interface optimization for imaging of evoked peripheral nervous system activity with electrical impedance tomography (EIT).

OBJECTIVE: Non-invasive imaging techniques are undoubtedly the ideal methods for continuous monitoring of neural activity. One such method, fast neural electrical impedance tomography (EIT) has been developed over the past decade in order to image neural action potentials with non-penetrating electrode arrays. APPROACH: The goal of this study is two-fold. First, we present a detailed fabrication method for silicone-based multiple electrode arrays which can be used for epicortical or neural cuff applications. Secondly, we optimize electrode material coatings in order to achieve the best accuracy in EIT reconstructions. MAIN RESULTS: The testing of nanostructured electrode interface materials consisting of platinum, iridium oxide, and PEDOT:pTS in saline tank experiments demonstrated that the PEDOT:pTS coating used in this study leads to more accurate reconstruction dimensions along with reduced phase separation between recording channels. The PEDOT:pTS electrodes were then used in vivo to successfully image and localize the evoked activity of the recurrent laryngeal fascicle from within the cervical vagus nerve. SIGNIFICANCE: These results alongside the simple fabrication method presented here position EIT as an effective method to image neural activity.

Validation of a finite-element solution for electrical impedance tomography in an anisotropic medium.

Electrical impedance tomography is an imaging method, with which volumetric images of conductivity are produced by injecting electrical current and measuring boundary voltages. It has the potential to become a portable non-invasive medical imaging technique. Until now, implementations have neglected anisotropy even though human tissues such as bone, muscle and brain white matter are markedly anisotropic. We present a numerical solution using the finite-element method that has been modified for modelling anisotropic conductive media. It was validated in an anisotropic domain against an analytical solution in an isotropic medium after the isotropic domain was diffeomorphically transformed into an anisotropic one. Convergence of the finite element to the analytical solution was verified by showing that the finite-element error norm decreased linearly related to the finite-element size, as the mesh density increased, for the simplified case of Laplace's equation in a cubic domain with a Dirichlet boundary condition.

Reproducibility of regional lung ventilation distribution determined by electrical impedance tomography during mechanical ventilation.

Electrical impedance tomography (EIT) has the potential to become a new tool for bedside monitoring of regional lung ventilation. The aim of our study was to assess the reproducibility of regional lung ventilation distribution determined by EIT during mechanical ventilation under identical ventilator settings. The experiments were performed on 10 anaesthetized supine pigs ventilated in a volume-controlled mode. EIT measurements were performed with the Goe-MF II device (Viasys Healthcare, Höchberg, Germany) during repeated changes in positive end-expiratory pressure (PEEP) from 0 to 10 cm H2O. Regional lung ventilation was determined in the right and left hemithorax as well as in 64 regions of interest evenly distributed over each chest side in the ventrodorsal direction. Ventilation distributions in both lungs were visualized as ventrodorsal ventilation profiles and shifts in ventilation distribution quantified in terms of centres of ventilation in relation to the chest diameter. The proportion of the right lung on total ventilation in the chest cross-section was 0.54+/-0.04 and remained unaffected by repetitive PEEP changes. Initial PEEP increase resulted in a redistribution of ventilation towards dorsal lung regions with a shift of the centre of ventilation from 45+/-3% to 49+/-3% of the chest diameter in the right and from 47+/-2% to 50+/-2% in the left hemithorax. Excellent reproducibility of the results in the individual regions of interest with almost identical patterns of ventilation distribution was found during repeated PEEP changes.

Numerical modelling errors in electrical impedance tomography.

Electrical impedance tomography (EIT) is a non-invasive technique that aims to reconstruct images of internal impedance values of a volume of interest, based on measurements taken on the external boundary. Since most reconstruction algorithms rely on model-based approximations, it is important to ensure numerical accuracy for the model being used. This work demonstrates and highlights the importance of accurate modelling in terms of model discretization (meshing) and shows that although the predicted boundary data from a forward model may be within an accepted error, the calculated internal field, which is often used for image reconstruction, may contain errors, based on the mesh quality that will result in image artefacts.

A review of errors in multi-frequency EIT instrumentation.

Multi-frequency electrical impedance tomography (MFEIT) was proposed over 10 years ago as a potential spectroscopic impedance imaging method. At least seven systems have been developed for imaging the lung, heart, breast and brain, yet none has yet achieved clinical acceptance. While the absolute impedance varies considerably between different tissues, the changes in the spectrum due to physiological changes are expected to be quite small, especially when measured through a volume. This places substantial requirements on the MFEIT instrumentation to maintain a flat system frequency response over a broad frequency range (dc-MHz). In this work, the EIT measurement problem is described from a multi-frequency perspective. Solutions to the common problems are considered from recent MFEIT systems, and the debate over four-terminal or two-terminal (multiple source) architecture is revisited. An analysis of the sources of MFEIT errors identifies the major sources of error as stray capacitance and common-mode voltages which lead to a load dependence in the frequency response of MFEIT systems. A system that employs active electrodes appears to be the most able to cope with these errors (Li et al 1996). A distributed system with digitization at the electrode is suggested as a next step in MFEIT system development.

Exam room, chair side evaluation of retinal edema: improving accuracy and precision for identification of subclinical diabetic macular edema.

BACKGROUND: Early detection of diabetic macular edema (DME) is important for improving patient outcomes. Currently, the gold standards are slit lamp stereo biomicroscopy examination and fluorescein angiography (FA). Detecting DME with a slit lamp is subjective and can be difficult in the early stages of the disease. FA is invasive and involves discomfort and risk to the patient. A new diagnostic test, the Heidelberg Retina Tomograph (HRT) Retina Module (Heidelberg Engineering, Heidelberg, Germany), is noninvasive, objective, and sensitive to early changes in the retina. It is purported to locate and quantify retinal edema such as DME, independent of retina thickening. Presented are a series of case reports comparing retinal photography, FA, HRT, and ocular coherence tomography (Stratus OCT; Carl Zeiss Meditec, Jena, Germany) results on patients with DME. The purpose is to determine the clinical utility of the HRT for discerning DME compared with clinical stereo biomicroscopy impression and FA. CASE REPORTS: In this representative case series, the author's first stereo biomicroscopy impression, macular photographs, retinal fluorescein angiographs, Stratus OCT images, and HRT Retina Module images from 5 type 2 diabetic patients (3 insulin and 2 non-insulin dependent) with retinopathy are presented. All patients are men, with a mean age of 56.4 (range, 51 to 62). Subjects had diabetes mellitus type 2 for an average of 14.4 years (range, 10 to 22) and were experiencing fluctuations or loss in vision. In all cases, DME was clearly identifiable on FA although sometimes questionable by stereo biomicroscopy. Nonstereo retinal photos and OCT examinations were inconclusive or unremarkable in 4 of 5 cases. The HRT Edema surrogate "e" index and map results showed areas of DME that were very similar to those of the FA images. CONCLUSIONS: In this case series, the HRT Retina Module provided useful clinical information on DME patients including the quantification and extent of both subclinical and clinically significant DME. Although more rigorous study is warranted, such immediate feedback from a noninvasive, safe, diagnostic tool is invaluable in clinical practice, particularly with the advent of prophylactic nutritional genistein-based multivitamin supplements such as Bausch & Lomb Ocuvite DF (Rochester, New York).

Two-layer heterogeneous breast phantom for photoacoustic imaging.

Photoacoustic tomography (PAT) is emerging as a potentially important aid for breast cancer detection. Well-validated tissue-simulating phantoms are needed for objective, quantitative, and physically realistic testing for system development. Prior reported PAT phantoms with homogenous structures do not incorporate the irregular layered structure of breast tissue. To assess the impact of this simplification, we design and construct two-layer breast phantoms incorporating vessel-simulating inclusions and realistic undulations at the fat/fibroglandular tissue interface. The phantoms are composed of custom poly(vinyl chloride) plastisol formulations mimicking the acoustic properties of two breast tissue types and tissue-relevant similar optical properties. Resulting PAT images demonstrate that in tissue with acoustic heterogeneity, lateral size of imaging targets is sensitive to the choice of sound speed in image reconstruction. The undulating boundary can further degrade a target's lateral size due to sound speed variation in tissue and refraction of sound waves at the interface. The extent of this degradation is also influenced by the geometric relationship between an absorber and the boundary. Results indicate that homogeneous phantom matrixes may underestimate the degradation of PAT image quality in breast tissue, whereas heterogeneous phantoms can provide more realistic testing through improved reproduction of spatial variations in physical properties.

A Versatile Noise Performance Metric for Electrical Impedance Tomography Algorithms.

Electrical impedance tomography (EIT) is an emerging technology for real-time monitoring of patients under mechanical ventilation. EIT has the potential to offer continuous medical monitoring while being noninvasive, radiation free, and low cost. Due to their ill-posedness, image reconstruction typically uses regularization, which implies a hyperparameter controlling the tradeoff between noise rejection and resolution or other accuracies. In order to compare reconstruction algorithms, it is common to choose hyperparameter values such that the reconstructed images have equal noise performance (NP), i.e., the amount of measurement noise reflected in the images. For EIT many methods have been suggested, but none work well when the data originate from different measurement setups, such as for different electrode positions or measurement patterns. To address this issue, we propose a new NP metric based on the average signal-to-noise ratio in the image domain. The approach is validated for EIT using simulation experiments on a human thorax model and measurements on a resistor phantom. Results show that the approach is robust to the measurement configuration (i.e., number and position of electrodes, skip pattern) and the reconstruction algorithm used. We propose this novel approach as a way to select optimized measurement configurations and algorithms.

Problems and Possibilities of Passive Thermoacoustical Tomography.

The problems and possibilities of passive thermoacoustical tomography are discussed. Algorithms for reconstruction of internal temperature in the human body are proposed. These algorithms take into account heat transfer and blood circulation and the absorption factor, obtained previously. The results of reconstruction of deep temperature in the human hand in simulations with the medium with a heated object are reported. These results support the possibility of the correlation measurements of the thermal acoustic radiation. Such measurements allow the information on ultrasound absorption by the object under study to be obtained and open the way to the development of a passive acoustic tomography system using a priori information on the absorption factor.

The quality of reporting of diagnostic accuracy studies in glaucoma using the Heidelberg retina tomograph.

PURPOSE: Scanning laser tomography with the Heidelberg retina tomograph (HRT; Heidelberg Engineering, Heidelberg, Germany) has been proposed as a useful diagnostic test for glaucoma. This study was conducted to evaluate the quality of reporting of published studies using the HRT for diagnosing glaucoma. METHODS: A validated Medline and hand search of English-language articles reporting on measures of diagnostic accuracy of the HRT for glaucoma was performed. Two reviewers selected and appraised the papers independently. The Standards for Reporting of Diagnostic Accuracy (STARD) checklist was used to evaluate the quality of each publication. RESULTS: A total of 29 articles were included. Interobserver rating agreement was observed in 83% of items (kappa=0.76). The number of STARD items properly reported ranged from 5 to 18. Less than a third of studies (7/29) explicitly reported more than half of the STARD items. Descriptions of key aspects of the methodology were frequently missing. For example, the design of the study (prospective or retrospective) was reported in 6 of 29 studies, and details of participant sampling (e.g., consecutive or random selection) were described in 5 of 29 publications. The commonest description of diagnostic accuracy was sensitivity and specificity (25/29) followed by area under the ROC curve (13/29), with 9 of 29 publications reporting both. CONCLUSIONS: The quality of reporting of diagnostic accuracy tests for glaucoma with HRT is suboptimal. The STARD initiative may be a useful tool for appraising the strengths and weaknesses of diagnostic accuracy studies.