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keratoconus, that require knowledge of disease severity shape of corneal opacities in corneas of keratoconus patients.36
measured on an ordinal scale. In the Gestalt scarring assessment, the reader takes into ac-
count how close the scarring as a whole is to the line of sight
and how large and dense is the scarring to estimate the overall
MATERIALS AND METHODS (gestalt) scarring. Table 1 defines the gestalt scarring scale.
Intraclass correlation coefficients for readers reading the same
Developing the Severity Score slides of corneal scarring (masked) on a repeated basis indicate
Many indices derived from corneal topography were very good reliability.37 The test–retest reliability for gestalt
initially evaluated as potential candidates for inclusion in the grading for random rereads for all readers for each year from
new scale to meet the above-mentioned criteria. Simulated 1998 to 2004 were 0.77, 0.49, 0.80, 0.71, 0.54, 0.72, and 0.61,
indices were computed and incorporated in the Ohio State respectively. Over this 6-year period, the test–retest reliability
Corneal Topography Tool (OSUCTT).35 These indices are was 0.66, which is typically considered very good (un-
simulated because they were initially derived from descriptions published data).
in the published literature and compared with the results A scale suitable for segregation analysis requires a range
provided by the proprietary instrument using them. For example, of quantitative classifications from normal to severely affected
ACP was developed for the TMS-1 instrument (Tomey cases. Our scale includes values for normal eyes, keratoconus
Technologies, Nagoya, Japan).31 In our previous studies, when suspects, and mild, moderate, and severe keratoconus. Un-
ACP was compared with the simulated ACP, there were usual corneas not caused by keratoconus referred to as atypical
discrepancies that could be explained only by manufacturer corneas were also included. Atypical eyes consisted of contact
modifications to the published formulas (unpublished data). In lens–induced warpage, penetrating keratoplasty, myopic
fact, this was the rule rather than the exception across instrument refractive surgery, and corneal scarring from disease or trauma
manufacturers for other simulated indices as well. These not associated with keratoconus. This resulted in a 5-point scale,
discrepancies required reverse engineering to improve the with 0 being normal and 5 indicating severe disease.
correlations between the ‘‘native instrument’’ output and that Testing of data consisted of 3 steps: evaluating a test
derived from the OSUCTT. Hence, for consistency across dataset and validating the scale results using 2 validation sets.
platforms, we used simulated indices in this study.
The first set of analyses to identify candidate topo- Test Dataset
graphic indices examined the correlation for several pairs of An initial test set of 1012 eyes was assembled to
indices. This analysis grouped 17 indices into 4 major groups: determine the combination of data ranges for each classifi-
those associated with corneal power, corneal asymmetry, cation criterion. The test set included subjects that clinically
corneal irregularity, and corneal cylinder (orthogonal astig- could be classified into each of these categories. The set
matism). Among the corneal power measures, the correlations included 130 normal eyes, 41 atypical eyes, 7 keratoconus-
were very high. ACP was chosen because the simulations were suspect eyes, and 834 eyes with keratoconus. Keratoconus
closest to the native machine output. Corneal asymmetry and suspects had corneal topography patterns suspicious for the
irregularity essentially represent higher-order optical aberra- disease but no slit-lamp or other clinical findings. Using 95%
tions, so we selected the third-order and higher RMS error confidence intervals (CIs), possible demarcation points were
(HORMSE; through the 27th term) to describe these features determined for HORMSE for each level. The cutpoints for
collectively. HORMSE was derived from raw corneal ACP were determined through clinical experience and 95% CI
topography data by VOL-CT software (version 6.58; Sarver and were defined as less than 52.00 D = mild, 52.00 to 56.00
and Associates, Carbondale, IL). Corneal astigmatism was not D = moderate, and more than 56.00 D = severe.
used in this scale. In previous studies (unpublished data), the
cylinder was not a very powerful diagnostic tool either in Validation Set 1
identifying keratoconus or in tracking its severity. A set of 128 right eyes, referred to as validation set 1,
In addition to these 2 topographic indices, the KSS also was subjected to ranking and compared with a clinician’s
used an analysis of topographic patterns. One observer
(T.T.M.) subjectively classified the topographic patterns using
an axial algorithm-displayed map as either normal, atypical
(but not keratoconus), or whether it exhibited an isolated area
of steepening characteristic for keratoconus. Finally, the KSS TABLE 1. Descriptors for Overall (Gestalt) Scarring (0.0–4.0
used clinical assessments of keratoconic slit-lamp signs, in 0.5 Steps)
specifically the presence or absence of Fleischer rings, Vogt Grade 1.0 Trace and not on LOS,
,1.5 mm total size
striae, and corneal scarring characteristic for keratoconus. The
Grade 2.0 Easily noticeable and approaching LOS,
scaling of scarring for KSS followed the protocol used for 1.5–2.5 mm total size
‘‘gestalt scarring’’ in the Collaborative Longitudinal Evalua- Grade 3.0 Dense but translucent and impinging on LOS,
tion of Keratoconus (CLEK) Study.36 total size 2.5 mm or greater
Gestalt scarring is a measure of the total scarring Grade 4.0 Opaque and on LOS, size 2.5 mm or greater
observed in the central cornea in CLEK Study corneal
Increased grade for density, size, number, and location near or on the line of
photographs. In a previous study, masked CLEK Photography sight (LOS).
Reading Center readers assessed the number, size, density, and
TABLE 4. Summary Statistics for 2 Keratoconus Measures, by KSS Level, Obtained from Test Set
0 1 2 3 4 5
ACP
Mean 43.82 44.10 44.57 47.10 53.89 62.81
Min 41.10 40.00 40.86 39.47 52.01 56.08
Max 47.66 47.01 46.83 51.97 55.98 90.38
SD 1.30 1.60 2.24 2.74 1.11 6.52
95% CI 41.22–46.42 40.90–44.30 40.09–49.05 41.62–52.58 51.67–56.11 49.77–75.85
HORMSE
Mean 0.42 0.60 0.70 1.98 3.14 5.03
Min 0.23 0.40 0.51 0.26 0.89 1.11
Max 0.75 1.0 0.96 9.48 8.00 55.66
SD 0.07 0.14 1.61 1.19 1.30 4.27
95% CI 0.28–0.56 0.32–0.88 0–3.93 0–4.36 0.54–5.74 0–13.57
Scores: 0, normal; 1, atypical normal; 2, keratoconus suspect; 3, keratoconus—mild; 4, keratoconus—moderate; 5, keratoconus—severe.
ACP, average corneal power; HORMSE, higher-order root mean square (Wavefront) error.
In other classification schemes, the shape of the cone- 12. Brancati F, Valente EM, Sarkozy A, et al. A locus for autosomal dominant
nipple (round), oval, or globus has been used to classify keratoconus maps to human chromosome 3p14-q13. J Med Genet. 2004;
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We present a severity rating scale, based on common 21. Heon E, Greenberg A, Kopp KK, et al. VSX1: a gene for posterior
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