The long-term postoperative effect of the Baerveldt glaucoma drainage device and of a trabeculectomy on the corneal endothelium.

PURPOSE: To determine whether the postoperative corneal endothelial cell density (ECD) differs between glaucoma patients who underwent Baerveldt implant (BGI) surgery and patients who underwent a trabeculectomy (TE) over 5 years ago. METHODS: Cross-sectional, observational study including 34 patients who underwent TE and 36 patients who underwent BGI surgery 5-11 years ago, as part of a randomized clinical trial. None of the patients had a history of intraocular surgery prior to their glaucoma surgery. Central and peripheral ECD was measured by using a non-contact specular microscope. RESULTS: Central and peripheral ECD in the TE group was 2285 ± 371 cells/mm2 (mean ± SD) and 2463 ± 476 cells/mm2 , respectively. Central and peripheral ECD in the BGI group was 1813 ± 745 cells/mm2 and 1876 ± 764 cells/mm2 , respectively. The central and peripheral ECD was statistically significantly higher in the TE group than in the BGI group (p = 0.001 for both). Additional intraocular surgical interventions were more prevalent in the BGI group (23) than in the TE group (5) (p < 0.001). In a subanalysis, without eyes that had undergone additional surgical interventions, only the peripheral ECD was statistically significantly higher in the TE group compared with the BGI group (p = 0.011). For the BGI group, a longer postoperative period resulted in a lower central ECD (r = -0.614, p = 0.004). CONCLUSION: Long-term ECD in eyes that underwent a BGI was considerably lower compared with eyes that underwent a TE, mainly in the peripheral cornea. This suggests that BGI causes a larger decrease of ECD than TE. Additionally, the decrease after BGI appears to continue for a longer period than after TE.

Ocular motility changes and diplopia in sutured versus unsutured implantation of the Baerveldt glaucoma device.

PURPOSE: To investigate the effect of two surgical techniques in primary Baerveldt glaucoma implant (BGI) surgery, that is the sutured technique and the unsutured (free) plate technique, on the ocular motility and prevalence of diplopia. We hypothesize that the free plate technique results in a lower diplopia prevalence. METHODS: We performed a prospective study of patients who underwent BGI surgery with the free plate technique and compared them with patients from a previous study who had undergone BGI surgery with the sutured technique. Their ductions, ocular alignment and fusion range and the prevalence of diplopia were measured before surgery and at 3 months, 6 months and 1 year postoperatively. RESULTS: We analysed 57 free plate and 51 sutured plate patients. One year postoperatively, we found no statistically significant difference in the prevalence of diplopia between the two techniques. All duction changes between baseline and 1-year follow-up were restrictions and occurred statistically significantly more frequently in the free plate than in the sutured plate group (p = 0.03; 60% versus 34%). About the ocular alignment, in the horizontal direction, a change in exodirection was more common in both groups, while in the vertical direction, a hyperdeviation of the operated eye was more common. The vertical ocular alignment change was smaller in the free plate group than in the sutured plate group (p = 0.04 at near and p = 0.02 at distance). CONCLUSIONS: One year postoperatively, the prevalence of diplopia was not significantly different between patients with the sutured plate and patients with the free plate technique. Both surgical techniques induce diplopia and changes in ocular motility and/or in ocular alignment.

[Artificial intelligence for eye care]. / Artificiële intelligentie in de oogzorg.

Technological developments in ophthalmic imaging and artificial intelligence (AI) create new possibilities for diagnostics in eye care. AI has already been applied in ophthalmic diabetes care. AI-systems currently detect diabetic retinopathy in general practice with a high sensitivity and specificity. AI-systems for the screening, monitoring and treatment of age-related macular degeneration and glaucoma are promising and are still being developed. AI-algorithms, however, only perform tasks for which they have been specifically trained and highly depend on the data and reference-standard that were used to train the system in identifying a certain abnormality or disease. How the data and the gold standard were established and determined, influences the performance of the algorithm. Furthermore, interpretability of deep learning algorithms is still an ongoing issue. By highlighting on images the areas that were critical for the decision of the algorithm, users can gain more insight into how algorithms come to a particular result.

Deep Learning for Assessing the Corneal Endothelium from Specular Microscopy Images up to 1 Year after Ultrathin-DSAEK Surgery.

Purpose: To present a fully automatic method to estimate the corneal endothelium parameters from specular microscopy images and to use it to study a one-year follow-up after ultrathin Descemet stripping automated endothelial keratoplasty. Methods: We analyzed 383 post ultrathin Descemet stripping automated endothelial keratoplasty images from 41 eyes acquired with a Topcon SP-1P specular microscope at 1, 3, 6, and 12 months after surgery. The estimated parameters were endothelial cell density (ECD), coefficient of variation (CV), and hexagonality (HEX). Manual segmentation was performed in all images. Results: Our method provided an estimate for ECD, CV, and HEX in 98.4% of the images, whereas Topcon's software had a success rate of 71.5% for ECD/CV and 30.5% for HEX. For the images with estimates, the percentage error in our method was 2.5% for ECD, 5.7% for CV, and 5.7% for HEX, whereas Topcon's software provided an error of 7.5% for ECD, 17.5% for CV, and 18.3% for HEX. Our method was significantly better than Topcon's (P < 0.0001) and was not statistically significantly different from the manual assessments (P > 0.05). At month 12, the subjects presented an average ECD = 1377 ± 483 [cells/mm2], CV = 26.1 ± 5.7 [%], and HEX = 58.1 ± 7.1 [%]. Conclusions: The proposed method obtains reliable and accurate estimations even in challenging specular images of pathologic corneas. Translational Relevance: CV and HEX, not currently used in the clinic owing to a lack of reliability in automatic methods, are useful biomarkers to analyze the postoperative healing process. Our accurate estimations allow now for their clinical use.

A very short version of the Visual Function Questionnaire (VFQ-3oo7) for use as a routinely applied Patient-Reported Outcome Measure.

BACKGROUND: Patient-reported outcome measures (PROMs) are valuable supplements in regular care to facilitate routine monitoring of quality of life from the patient's perspective. The 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) is a widely used PROM in ophthalmology. However, the NEI-VFQ-25 is too time-consuming and cumbersome for routine evaluations in regular care. The aim of this study is to construct a 7-item questionnaire of which only 3 items are presented to the patient, by means of routing. This VFQ 3 out of 7 (VFQ-3oo7) should have a minimal loss of information compared with the NEI-VFQ-25. METHODS: An historical database including 3293 administrations of the NEI-VFQ-25 was constructed involving patients with retinal detachment, cataract, corneal diseases, glaucoma, macular degeneration, uveal melanoma and a normal population sample. The data were subjected to Rasch analyses, in particular a generalized partial credit model. Items were sorted on the latent trait and divided into seven categories. From each category, the item with the highest discriminative value was selected. Through routing, only three out of the seven remaining questions are used, where the answers navigate patients to a fitting trait level. RESULTS: A one-dimensional structure was considered fitting. The VFQ-3oo7 showed a small loss of information compared with the total score of the NEI-VFQ-25: correlation 0.927 and a relative precision of 0.868. CONCLUSION: The very short, but valid, VFQ-3oo7 can be applied to evaluate the patient's perceived vision-related health status in routine evaluations of treatments in regular care, with a small burden for patients.

Motility Changes and Diplopia After Baerveldt Glaucoma Drainage Device Implantation or After Trabeculectomy.

PURPOSE: The purpose of this study was to quantify any diplopia and motility changes after the implantation of a Baerveldt glaucoma implant (BGI) or after trabeculectomy (TE). METHODS: We analyzed 51 patients with a BGI and 52 patients with a TE from a prospective cohort study. To quantify any diplopia, we asked patients about the presence of diplopia at 1 year after surgery. To quantify any ocular motility changes, we measured ductions in eight gaze directions, the patients' ocular alignment and their fusion range before and 1 year after surgery. RESULTS: In the BGI group, 14 patients (28%) experienced diplopia compared with one patient (2%) in the TE group (P < 0.001). Duction changes were more commonly observed in the BGI group (35%) than in the TE group (19%). In the BGI group, ductions were mostly restricted in elevation (13%; P < 0.001), in abduction (13%), in elevation in 25° adduction (13%; P = 0.044), and in elevation in 25° abduction (25%; P < 0.001). In 32% of the patients, their near horizontal ocular alignment shifted, notably in exodirection (P = 0.04). The fusion range decreased significantly in the horizontal direction (-12.6° ± 10.3°, mean ± standard deviation; P = 0.01). CONCLUSIONS: BGI surgery was significantly associated with postoperative diplopia and impaired eye motility (reduced ductions), mostly present in abduction, elevation, elevation in 25° adduction, and elevation in 25° abduction. Even without impaired ductions, diplopia could come about. TRANSLATIONAL RELEVANCE: By studying diplopia across glaucoma patients prospectively with diplopia questionnaires and extensive orthoptic measurements, we gain better insight into its occurrence.

Shared Care in Monitoring Stable Glaucoma Patients: A Randomized Controlled Trial.

PURPOSE: Comparing the quality of care provided by a hospital-based shared care glaucoma follow-up unit with care as usual. PATIENTS AND METHODS: This randomized controlled trial included stable glaucoma patients and patients at risk for developing glaucoma. Patients in the Usual Care group (n=410) were seen by glaucoma specialists. In the glaucoma follow-up unit group (n=405), patients visited the glaucoma follow-up unit twice followed by a visit to a glaucoma specialist. The main outcome measures were: compliance to the working protocol by glaucoma follow-up unit employees; difference in intraocular pressure between baseline and at ≥18 months; and patient satisfaction. RESULTS: Glaucoma follow-up unit employees closely adhered to the working protocol for the measurement of intraocular pressure, visual acuity and GDx (≥97.5% of all visits). Humphrey Field Analyzer examinations were not performed as frequently as prescribed by the working protocol, but more often than in the Usual Care group. In a small minority of patients that required back-referral, the protocol was disregarded, notably when criteria were only slightly exceeded. There was no statistically significant difference in changes in intraocular pressure between the 2 treatment groups (P=0.854). Patients were slightly more satisfied with the glaucoma follow-up unit employees than with the glaucoma specialists (scores: 8.56 vs. 8.40; P=0.006). CONCLUSIONS: In general, the hospital-based shared care glaucoma follow-up closely observed its working protocol and patients preferred it slightly over the usual care provided by medical doctors. The glaucoma follow-up unit operated satisfactorily and might serve as a model for shared care strategies elsewhere.

Patient satisfaction with glaucoma therapy: reality or myth?

While safe and effective treatments for glaucoma exist, their effectiveness is compromised by poor compliance. Patients who have problems with their topical glaucoma medication are acknowledged to be at higher risk for poor compliance, frequent medication switching, and surgery. Patient satisfaction with therapy and its associated benefits have until recently taken second place to efficacy. The present study is a transverse cross-sectional epidemiological survey among glaucoma patients receiving therapy with prostaglandin analogs. The primary objective was to determine and characterize patient satisfaction with glaucoma therapy, and the secondary objective was to identify factors that may contribute to poor patient satisfaction. Ophthalmologists in the Netherlands included 199 patients and 164 were analyzed. Patients were predominantly elderly with early, primary, open angle glaucoma. Eighty-nine percent of them stated they were satisfied or very satisfied with their treatment. However, signs of ocular surface disorder on ophthalmological examination were evident in 44% of patients, corneal fluorescein staining was positive in 28% of patients, and 38% of patients were using tear substitutes. The prevalence of blepharitis/meibomian gland dysfunction and dry eye was more than twice as high after the commencement of therapy compared with before therapy. Univariate analysis revealed that patient dissatisfaction with their glaucoma therapy was statistically significantly (P<0.001) associated with the presence of ocular surface disease, hyperemia, ocular signs, symptoms upon and between instillation, and the use of tear substitutes. Apparently, patients in the present study are satisfied with their treatment; 89% expressed satisfaction compared with only 11% who professed dissatisfaction. The results suggest that even if local adverse events and ocular surface disease, in particular, contribute to glaucoma patient dissatisfaction, only a minority of patients expressed such dissatisfaction. At the time of the study, most (94%) of the patients included were receiving preserved preparations. Further studies should evaluate the influence of preservative on patient satisfaction.

Accuracy of matching optic discs with visual fields: the European Structure and Function Assessment Trial (ESAFAT).

PURPOSE: To determine the ability of ophthalmologists across Europe to match stereoscopic optic disc photographs to visual fields of varying severity. DESIGN: Evaluation and comparison of 2 diagnostic tests. PARTICIPANTS: A total of 109 of 260 invited ophthalmologists in 11 European countries. These had participated in the previous European Optic Disc Assessment Trial (EODAT), a trial on glaucoma diagnostic accuracy based on optic discs only. METHODS: Each participant matched stereo optic disc photographs of 40 healthy and 48 glaucomatous eyes to a visual field chosen from 4 options per disc. The 4 presented visual fields included the corresponding one and 3 other visual fields, varying in severity. The matching accuracy and any inaccuracy per disease severity were calculated. Classification accuracy (as glaucomatous or healthy) was compared with EODAT data. Duplicate slides allowed for the assessment of intraobserver agreement. MAIN OUTCOME MEASURES: Accuracy of matching optic discs with their corresponding visual field and of classifying them as healthy or glaucomatous; intraobserver agreement (κ). RESULTS: The overall accuracy of ophthalmologists for correctly matching stereoscopic optic disc photographs to their visual fields was 58.7%. When incorrectly matched, the observers generally overestimated the visual field severity (P<0.001), notably in eyes with early glaucoma. The intraobserver agreement was, on average, moderate (0.52). CONCLUSIONS: European ophthalmologists correctly matched stereoscopic optic disc photographs to their corresponding visual field in only approximately 59% of cases. In most mismatches, the clinicians overestimated the visual field damage.

Surgical outcomes of the Baerveldt Glaucoma Implant: differences between surgical techniques in the Rotterdam Eye Hospital.

PURPOSE: During the last decades, the Baerveldt Glaucoma Implant (BGI) has proven effective in the surgical treatment of glaucoma. Various surgical procedures have been used for its implantation and these may yield different clinical outcomes and different intraoperative and postoperative complications. We evaluated the success rate of BGI and compared complications between 2 different surgical implantation techniques. METHODS: Retrospective analyses of medical records of consecutive adult patients who underwent a BGI implantation at the Rotterdam Eye Hospital between September 2007 and August 2008. Patients were divided by the surgical implantation technique. Success was defined as an intraocular pressure ≥6 mm Hg and ≤21 mm Hg as well as a reduction of ≥20% from preoperative values. Other outcome measures were intraoperative and postoperative complications and surgical revisions of the BGI. RESULTS: A total of 173 BGI procedures were performed during the study period. Only first-ever BGI implantations in adult patients were analyzed, yielding 141 implants for the analyses. The length of follow-up averaged 11.5 months (range, 0.3 to 24.7 mo) and the mean (SD) preoperative intraocular pressure was 25.6 (8.6). Overall success rates were 75% and 83%, respectively, for the 2 different groups (P=0.40 for differences between groups). Nine patients (6%) needed a reoperation, whereas complications were documented in another 9 patients without significant differences between groups. CONCLUSIONS: Overall complication rates of the BGI were low and they combined with high success rates. Outcomes did not differ between the various surgical techniques. The choice of a certain technique might therefore be based on differences in costs and length of surgery between these techniques.

Linkage and association analyses of glaucoma related traits in a large pedigree from a Dutch genetically isolated population.

BACKGROUND: Despite extensive research on the genetic determinants of glaucoma, the genes identified to date explain only a small proportion of cases in the general population. METHODS: Genome-wide linkage and association analyses of quantitative traits related to glaucoma were performed: intraocular pressure, size and morphology of the optic disc (individual and combined by method of principal components) and thickness of the retinal nerve fibre layer (RNFL), in a large pedigree from a genetically isolated Dutch population. RESULTS: For the size of the optic disc, the study demonstrated a significant linkage signal (logarithm of odds (LOD)=3.6) at the LRP1B region on chromosome 2q21.2-q22.2 and significant association (p=8.95×10(-12)) with the previously reported CDC7/TGFBR3 locus at 1p22. For parameters describing morphology of the optic disc, the study obtained significant linkage signal (LOD=4.6) at regions SIRPA and RNF24/PANK2 at 20p13 (false discovery rate (FDR) based q value <0.05) and genome-wide significant association (p=2.38×10(-9)) with a common variant in the RERE gene at 1p36. Suggestive linkage and association signals indicated loci for morphology of the optic disc at 2q31-q33 (IGFBP2 locus) and for RNFL thickness at 3p22.2 (DCLK3 locus) and 14q22-q23 (SIX1 locus). CONCLUSION: This study identified new linkage regions at 20p13 (SIRPA and RNF24/PANK2 loci) and 2q33-q34 (IGFBP2 locus) for parameters describing morphology of the optic disc. The results of the study also suggested common genetic control of these parameters and RNFL thickness by SIX1 and doublecotin family genes. Finally, association signals for the recently reported RERE and LRP1B loci and the well known CDC7, TGFBR3, and ATOH7 loci were replicated.

Cost-effectiveness of monitoring glaucoma patients in shared care: an economic evaluation alongside a randomized controlled trial.

BACKGROUND: Population aging increases the number of glaucoma patients which leads to higher workloads of glaucoma specialists. If stable glaucoma patients were monitored by optometrists and ophthalmic technicians in a glaucoma follow-up unit (GFU) rather than by glaucoma specialists, the specialists' workload and waiting lists might be reduced.We compared costs and quality of care at the GFU with those of usual care by glaucoma specialists in the Rotterdam Eye Hospital (REH) in a 30-month randomized clinical trial. Because quality of care turned out to be similar, we focus here on the costs. METHODS: Stable glaucoma patients were randomized between the GFU and the glaucoma specialist group. Costs per patient year were calculated from four perspectives: those of patients, the Rotterdam Eye Hospital (REH), Dutch healthcare system, and society. The outcome measures were: compliance to the protocol; patient satisfaction; stability according to the practitioner; mean difference in IOP; results of the examinations; and number of treatment changes. RESULTS: Baseline characteristics (such as age, intraocular pressure and target pressure) were comparable between the GFU group (n = 410) and the glaucoma specialist group (n = 405).Despite a higher number of visits per year, mean hospital costs per patient year were lower in the GFU group (€139 vs. €161). Patients' time and travel costs were similar. Healthcare costs were significantly lower for the GFU group (€230 vs. €251), as were societal costs (€310 vs. €339) (p < 0.01). Bootstrap-, sensitivity- and scenario-analyses showed that the costs were robust when varying hospital policy and the duration of visits and tests. CONCLUSION: We conclude that this GFU is cost-effective and deserves to be considered for implementation in other hospitals.

Clinical assessment of stereoscopic optic disc photographs for glaucoma: the European Optic Disc Assessment Trial.

PURPOSE: To determine the diagnostic accuracy of judging optic disc photographs for glaucoma by ophthalmologists. DESIGN: Evaluation of diagnostic test and technology. PARTICIPANTS: A total of 243 of 875 invited ophthalmologists in 11 European countries. METHODS: We determined how well each participant classified 40 healthy eyes and 48 glaucomatous eyes with varying severity of the disease on stereoscopic slides. Duplicate slides were provided for determining intraobserver agreement. All eyes were also imaged with the GDx with variable corneal compensation (GDx-VCC) (Carl Zeiss Meditec AG, Jena, Germany) and the Heidelberg Retina Tomograph (HRT) I (Heidelberg Engineering GmbH, Heidelberg, Germany). Diagnostic accuracies of clinicians were compared with those of the best machine classifiers. MAIN OUTCOME MEASURES: Accuracy of classification, expressed as sensitivity, specificity, and overall accuracy. Intraobserver agreement (kappa). RESULTS: The overall diagnostic accuracy of ophthalmologists was 80.5% (standard deviation [SD], 6.8; range, 61.4%-94.3%). The machine classifiers outperformed most observers in diagnostic accuracy; the GDx-VCC nerve fiber indicator and the HRT's best classifier correctly classified 93.2% and 89.8% of eyes, respectively. The intraobserver agreement (kappa) varied between -0.13 and 1.0 and was on average good (0.7). CONCLUSIONS: In general, ophthalmologists classify optic disc photographs moderately well for detecting glaucoma. There is, however, large variability in diagnostic accuracy among and agreement within clinicians. Common imaging devices outperform most clinicians in classifying optic discs. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Creating patient value in glaucoma care: applying quality costing and care delivery value chain approaches--a five-year case study in the Rotterdam Eye Hospital.

PURPOSE: The purpose of this paper is to explore in a specific hospital care process the applicability in practice of the theories of quality costing and value chains. DESIGN/METHODOLOGY/APPROACH: In a retrospective case study an in-depth evaluation of the use of a quality cost model (QCM) and the applicability of Porter's care delivery value chain (CDVC) was performed in a specific care process: glaucoma care over the period 2001 to 2006 in the Rotterdam Eye Hospital in The Netherlands. FINDINGS: The case study shows a reduction of costs per product by increasing the number of outpatient visits and surgery combined with a higher patient satisfaction. Reduction of costs of non-compliance by using the QCM is small, due to the absence of (external) financial incentives for both the hospital and individual physicians. For CDVC to be supportive to an integrated quality and cost management the notion "patient value" needs far more specification as mutually agreed on by the stakeholders involved and related reimbursement needs to depend on realised outcomes. RESEARCH LIMITATIONS/IMPLICATIONS: The case study just focused on one specific care process in one hospital. To determine effects in other areas of health care, it is important to study the use and applicability of the QCM and the CDVC in other care processes and settings. ORIGINALITY/VALUE: QCM and a CDVC can be useful tools for hospital management to manage the outcomes on both quality and costs, but impact is dependent on the incentives in the context of the existing organisational and reimbursement system and asks for an agreed on operationalisation among the various stakeholders of the notion of patient value.

Enhanced imaging algorithm for scanning laser polarimetry with variable corneal compensation.

PURPOSE: To describe and investigate a method of improving assessment of retinal nerve fiber layer (RNFL) morphology with scanning laser polarimetry (SLP) with variable corneal compensation (VCC). METHODS: By neutralizing anterior segment birefringence with a variable compensator, the current VCC method allows direct measurement of RNFL retardation. In the new method, enhanced corneal compensation (ECC), the variable compensator was set to introduce a "bias" birefringence. This bias was removed mathematically for each individual pixel to produce the RNFL image. In 177 eyes of healthy subjects, patients with glaucoma, and subjects with ocular hypertension, retardation images were obtained with both VCC and ECC. RESULTS: In the tested eyes, images obtained with ECC showed the expected RNFL appearance better than those obtained with VCC. In addition, the typical scan score, which quantifies the amount of atypia, was higher with ECC than with VCC. The amount of residual anterior segment birefringence dropped significantly with ECC in the various groups. Measurements of peripapillary RNFL retardation showed reduced temporal and nasal values with ECC, whereas superior and inferior values were not significantly different between VCC and ECC. The dynamic range appeared to have increased with ECC. The accuracy of the TSNIT (temporal, superior, nasal, inferior, temporal) average and inferior average for detecting glaucoma was higher with ECC than with VCC. CONCLUSIONS: RNFL morphology may be better assessed with the presented ECC method than with standard VCC. ECC may be implemented in the current VCC systems by means of a software upgrade. It may enhance the clinical utility of the GDx VCC in glaucoma management.

Effects of inadequate anterior segment compensation on measurements with scanning laser polarimetry.

The effects of poor anterior segment compensation on scanning laser polarimetry measurements of the retinal nerve fiber layer (RNFL) were systematically explored. A prototype scanning laser polarimeter with an adjustable compensator to neutralize anterior segment birefringence was used. By systematically varying the magnitude and axis of anterior segment compensation in a healthy and a glaucomatous eye, marked changes were observed in RNFL appearance: the healthy eye could appear to have glaucomatous damage, whereas the glaucomatous eye could appear to have a thicker and healthier RNFL. Even small amounts of uncompensated corneal birefringence, which may occur in routine clinical use, resulted in apparent changes in RNFL morphology. Knowledge of this effect is important for clinicians when using scanning laser polarimetry in clinical practice.

Clinician change detection viewing longitudinal stereophotographs compared to confocal scanning laser tomography in the LSU Experimental Glaucoma (LEG) Study.

PURPOSE: To compare optic nerve head (ONH) surface change detection by confocal scanning laser tomography (CSLT) within the LSU Experimental Glaucoma (LEG) study to expert clinicians viewing the LEG stereophotographs. DESIGN: Experimental study. PARTICIPANTS: Four fellowship-trained glaucoma specialists. METHODS: In the LEG study, six 15 CSLT images (TopSS, Laser Diagnostics Technologies, San Diego, CA) and four 2x optic disc stereophotographs were obtained from both eyes of 12 monkeys on 3 separate days and then every 2 weeks after laser to one eye (study eye) to elevate intraocular pressure. ONH surface change detection within the CSLT images is described in our companion report. In this report, the preliminary study compared change detection by the CSLT multivariate strategy with that of a single clinician viewing stereophotograph pairs on three separate occasions as the "gold standard." The main study compared change detection by three additional clinicians viewing a subset of LEG stereophotograph pairs on three separate occasions with that of the CSLT multivariate strategy as the "gold standard." Clinician change detection was assessed for partial (two of three occasions) or complete (three of three occasions) agreement. Three comparison groups within the main study are emphasized: 44 group A comparisons assessed false-positive change detection (specificity); 38 group B comparisons assessed change detection within 38 instances (11 onset and 27 progression events) of CSLT-detected study eye change; and 30 group C comparisons assessed change detection within 30 instances in which the CSLT failed to detect change in study eyes. MAIN OUTCOME MEASURES: Clinician change detection within each comparison with either partial or complete agreement. RESULTS: Within the main study, intrareading (-.29 to 0.67) and interreading (0.24--0.56) session agreement for each clinician was slight to moderate by kappa test. Good specificity (less than 10% false-positive change detection) was achieved within the 44 group A comparisons by two of the three clinicians, but only when the more stringent criterion (change detection on three of three occasions) was applied. Of the 38 group B comparisons (in which the CSLT detected change), the two clinicians who achieved good specificity in group A failed to detect change in 25 and 16 instances, respectively, using the more stringent (three of three) criterion. Similarly, of the 30 group C comparisons (in which the CSLT failed to detect change), these two clinicians detected change in three and seven instances, respectively, but in only one comparison did they both detect change. CONCLUSIONS: This study provides the first direct evidence that an existing CSLT may reasonably meet or exceed the ONH surface change detection performance of fellowship-trained glaucoma specialists in at least those eyes with good CSLT reproducibility.