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Sophie Rogers
University of Melbourne
University of Melbourne
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Paul P Connell
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Original Article
INTRODUCTION
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TABLE 1. KeithWagenerBarker and simplified classification systems for hypertensive retinopathy
KWB
Simplified classification
Grade
Features
Grade
Features
1
2
None
Mild
Moderate
Malignant
No detectable signs
Generalized arteriolar narrowing, focal arteriolar narrowing,
arteriovenous nicking, opacity (copper wiring) of arteriolar
wall or a combination of these signs
Retinal hemorrhages (blot-shaped, dot-shaped, or flame-shaped),
microaneurysm, cotton wool spot, hard exudate or a combination
of these signs
Signs of moderate retinopathy plus swelling of the optic disk
KWB, KeithWagenerBarker.
grading were 0.784 and 0.683 for the optometrist and retinal
specialist, respectively; the interobserver kappa between
the two clinicians was 0.660.
Intraobserver agreement
RESULTS
Interobserver agreement
Statistical data summarizing the interobserver level of
agreement are provided in Table 2. For the KWB system,
the interobserver kappa values for grading when compared
with the gold standard grading were 0.724 and 0.661 for
the optometrist and retinal specialist, respectively; the
interobserver kappa between the two clinicians was
0.661. For the simplified system, the interobserver kappa
values for grading when compared with the gold standard
2
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DISCUSSION
This study has compared the interobserver and intraobserver level of agreement between an optometrist and
a retinal specialist, for categorizing degrees of hypertensive
retinopathy from digital retinal images, using the KWB
and the proposed simplified classification system. Both
clinicians demonstrated a good level of agreement with
the KWB and the simplified classification system compared
with a gold standard grader; there was no significant
difference in the level of agreement for either of the two
classification methods, for either observer. The degree of
interagreement between the two clinicians also did not
differ significantly for either hypertensive classification
system. Intraobserver agreement, as measured using a
repeat grading by each clinician at a time point 6 months
after the initial grading, revealed that both the optometrist
and retinal specialist demonstrated a good level of
classification agreement using the KWB system. For the
simplified classification system, intraobserver agreement
was rated as very good and good for the optometrist and
retinal specialist, respectively.
At present, there is no well established consensus regarding the optimal method of classification for hypertensive
TABLE 2. Interobserver agreement [kappa (standard error),
n 100 image sets] for KeithWagenerBarker and
the simplified hypertensive classification systems
KWB
Simplified
0.724 (0.06)
0.661 (0.06)
0.661 (0.06)
0.784 (0.07)
0.683 (0.07)
0.660 (0.07)
KWB, KeithWagenerBarker.
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Optometrist
Retinal specialist
KWB
Simplified
0.770 (0.12)
0.702 (0.12)
0.879 (0.14)
0.671 (0.14)
KWB, KeithWagenerBarker.
AV nicking
Focal arteriolar
narrowing
Copper wiring
AV nicking
(c)
(d)
Retinal hemorrhage
Cotton wool patch
Retinal hemorrhages
Retinal hemorrhage
Retinal hemorrhage
(e)
(f)
Cotton wool patch
Retinal hemorrhage
Hard exudate
Retinal hemorrhage
FIGURE 1 Representative digital retinal fundus photographs of mild (a, b), moderate (c, d), and malignant (e, f) hypertensive retinopathy, as graded with the simplified
classification. (a) Mild hypertensive retinopathy is indicated by the presence of generalized arteriolar narrowing, arteriovenous nicking and opacification of the arteriolar
wall (copper wiring). (b) Mild hypertensive retinopathy with focal arteriolar narrowing. (c and d) Moderate hypertensive retinopathy with multiple retinal hemorrhages and
cotton wool patches. (e and f) Malignant hypertensive retinopathy with swelling of the optic disk, retinal hemorrhages, hard exudates, and cotton wool patches.
Journal of Hypertension
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TABLE 4. Summary of the association between the simplified classification of hypertensive retinopathy and cardiovascular disease
outcomes
Grade
Retinal signs
None
Mild
No detectable signs
Generalized arteriolar narrowing, focal arteriolar narrowing,
arteriovenous nicking, opacity (copper wiring) of arteriolar
wall or a combination of these signs
Hemorrhage (blot-shaped, dot-shaped, or flame-shaped),
microaneurysm, cotton wool spot, hard exudate or a
combination of these signs
None
Modest association with risk of incident stroke [23],
subclinical stroke [41], renal dysfunction [27],
incident coronary heart disease [25,28], and death [43]
Strong association with risk of incident stroke [23,24],
cardiovascular mortality [29], cognitive decline [42],
transient ischemic attack, and acute ischemic stroke [30],
and stroke mortality [31]
Strong association with death [11]
Moderate
Malignant
a
Modest association is denoted by an odds ratio greater than 1 but less than 2. Strong association is denoted by an odds ratio greater than 2.
(a)
6.35
CWS
4.71
Microaneurysm
4.24
Blot hemorrhage
1.69
AV nicking
1.49
Generalized narrowing
1.16
Focal narrowing
0.74
No retinopathy
0
(b)
19.1
CWS
18.7
Hemorrhage
17.3
Microaneurysm
AV nicking
8.0
Generalized narrowing
8.1
7.2
Focal narrowing
4.8
No retinal signs
0.0
5.0
10.0
15.0
20.0
25.0
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ACKNOWLEDGEMENTS
Conflicts of interest
The authors do not have any potential conflicts of interest
relevant to this research. CERA receives operational
infrastructure support from the Government of Victoria.
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35.
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Therefore, a classification system of hypertensive retinopathy based on more recent data and its reliability is of
interest. The study is straight forward. The statistical analyses
performed are sound. The manuscript is well written.
Reviewer 2
The authors propose a new classification of hypertensive
retinopathy that is in good agreement with the Keith,
Wagener and Barker classification. The KeithWegener
Barker grading system was widely applied in the last
decades for the stratification of risk in hypertensive
patients. However, several studies have proved a weak
clinical usefulness of this classification, due to poor reproducibility and poor association with other indices of target
organ damage. This limits extensive clinical application of
the examination of the fundus oculi. Newer approaches,
such as that proposed by the authors, could potentially give
us better information about retinal damage in hypertension.
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