Low Sensitivity of the Van Herick Method for Detecting Gonioscopic Angle Closure Independent of Observer Expertise

Am J Ophthalmol. 2018 Nov:195:63-71. doi: 10.1016/j.ajo.2018.07.026. Epub 2018 Jul 31.


Purpose: To evaluate the diagnostic performance characteristics of the Van Herick assessment (VHA) for identifying angle closure compared to gold-standard gonioscopy, as conducted by trained observers of varying expertise.

Design: Reliability analysis.

Methods: Patients (n = 131) from a glaucoma referral clinic aged ≥50 years without prior ocular surgery or iridotomy underwent unilateral VHA by 1 of 11 trained ophthalmic technicians, followed by VHA and indirect gonioscopy by 1 of 15 ophthalmology residents and 1 of 4 glaucoma specialist attending physicians. Observers were masked to others' gradings. Cohen's kappa (κ) assessed test reproducibility. VHA sensitivity and specificity for identifying gonioscopic angle closure were calculated.

Results: Mean patient age was 62.0 ± 8.7 years, 56% of patients were male, and 84% were African American. Angles were gonioscopically closed in 14.5% of eyes. Moderate agreement was observed comparing technician or resident VHA to attending VHA (κ = 0.48 and κ = 0.56, respectively). Resident and attending gonioscopy demonstrated excellent agreement (κ = 0.94). Sensitivities of technician, resident, and attending VHA for detecting angle closure were 57.9% (95% confidence interval: 34.0%-78.9%), 78.9% (53.9%-93.0%), and 68.4% (43.5%-86.4%), respectively. Specificities were 88.5% (80.3%-93.6%), 88.2% (80.3%-93.3%), and 87.5% (79.6%-92.8%), respectively.

Conclusions: VHA, even when performed by experienced ophthalmologists, misses a substantial proportion of angle closure while incorrectly identifying roughly 1 in 8 open-angle eyes as closed. These results suggest that clinical assessment of anterior chamber angle configuration is best accomplished with gonioscopy.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anterior Chamber / pathology*
  • Diagnostic Techniques, Ophthalmological*
  • Female
  • Glaucoma, Angle-Closure / diagnosis*
  • Gonioscopy / methods*
  • Health Personnel
  • Humans
  • Internship and Residency
  • Intraocular Pressure
  • Male
  • Middle Aged
  • Observer Variation
  • Ophthalmologists
  • Professional Competence
  • ROC Curve
  • Reproducibility of Results
  • Sensitivity and Specificity