Correspondence
Re: Staurenghi et al.: Proposed lexicon
for anatomic landmarks in normal
posterior segment spectral-domain
optical coherence tomography: the
INOCT consensus
(Ophthalmology 2014;121:1572-8)
Dear Editor:
I read with interest the “Proposed lexicon for anatomic landmarks
in normal posterior segment spectral-domain optical coherence to-
mography” by the International Nomenclature for Optical Coher-
ence Tomography Panel recently published in Ophthalmology.1
It is a comprehensive, reliable, and accurate discussion about
various layers visible in spectral-domain optical coherence to-
mography of the macula. The only ambiguity remaining is about the
hyporeflective layer between the interdigitation zone (layer number
13) and the retinal pigment epithelium (RPE)/Bruch membrane
complex (layer number 14). This layer seems to correspond with
the apical portion of the cytoplasm of the RPE cell containing
melanin granules and endoplasmic reticulum.2 I suggest that a name
such as “apical RPE cystoplasm” be given to this zone.
TOUKA BANAEE, MD
Department of Ophthalmology, Retina Research Center, Mashhad
University of Medical Sciences, Mashhad, Iran
Financial Disclosure(s): The author has no proprietary or commercial
interest in any materials discussed in this article.
Correspondence:
Touka Banaee, MD, Mashhad University of Medical Sciences, Department
of Ophthalmology, Khatam-al-anbia Hospital, Ghareni Boulevard, Mashhad,
Khorasan Razavi 91959 61151 Iran. E-mail: banaeet@mums.ac.ir.
References
1. Staurenghi G, Sadda S, Chakravarthy U, et al. Proposed lexicon
for anatomic landmarks in normal posterior segment spectral-
domain optical coherence tomography: the INOCT
consensus. Ophthalmology 2014;121:1572–8.
2. Thumann G, Duo G, Wang Y, et al. Cell biology of the retinal
pigment epithelium. In: Ryan SJ, Sadda S, Hinton D, eds.
Retina. Vol. 1. 5th ed. New York: Elsevier; 2013.
Author reply
Dear Editor:
We thank Dr Banaee for his thoughtful letter. The zone between the
interdigitation zone and the retinal pigment epithelial (RPE) inner
surface would be a zone that is relatively homogenous, composed of
the apical processes of the retinal pigment epithelial cells and the rod
outer segments. Immediately above that, the interdigitation zone is a
region containing the terminations of the cone outer segments and the
more vitreal side portions of the apical processes. Below that are the
main bodies of the retinal pigment epithelial cells. Although the name
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apical RPE cytoplasm does identify one of the components, it does not
mention the other significant feature.
Dr Banaee has identified a region that remains unnamed currently.
Future meetings of the INOCT consortium will address this matter.
GIOVANNI STAURENGHI, MD, FARVO1
RICK SPAIDE, MD2
USHA CHAKRAVARTHY, FRCOPHTH, PHD3
SRINIVAS SADDA, MD4
1
Department of Ophthalmology, Eye Clinic, Department of Biomedical
and Clinical Sciences “Luigi Sacco,” Sacco Hospital, University of
Milan, Milan, Italy; 2Vitreous Retina Macula Consultants of New York,
New York, New York; 3Queens University, Belfast, United Kingdom;
4
Department of Ophthalmology, Keck School of Medicine of the
University of Southern California, Los Angeles, California
Financial Disclosure(s): The author has made the following disclosures.
G.S.: Grant e Optovue; Consultant e Carl Zeiss Meditec, Optos, Hei-
delberg Engineering, Novartis, Alcon, Allergan, GlaxoSmithKline,
Roche, Genentech, OD-OS, Bayer; Speaker’s Bureau e Novartis, Zeiss,
Allergan, Alcon.
R.S.: Consultant e Topcon.
Correspondence:
Giovanni Staurenghi, MD, FARVO, Eye Clinic, Luigi Sacco Hospital,
University of Milan, Department of Clinical Science “Luigi Sacco,” via
G.B. Grassi, 74, Milan 20135, Italy. E-mail: giovanni.staurenghi@
unimi.it.
Re: Tham et al.: Global prevalence of
glaucoma and projections of glaucoma
burden through 2040: a systematic
review and meta-analysis
(Ophthalmology 2014;121:2081-90)
Dear Editor:
We read with interest the article by Tham et al.1 The authors strive
to provide an “accurate estimation of the current glaucoma
prevalence and future projections of the number of people with
glaucoma” based on existing literature. Regarding angle-closure
glaucoma (ACG) in non-Asian populations, we would like to
opine that this is very difficult to estimate at present, owing to the
meager amount and quality of available data. This fact was not
highlighted by the authors.
The authors scanned the available literature for quality prevalence
studies, and included subsequently in this review only 7 publications
that provide ACG prevalence rates in non-Asians (references 56, 60,
61, 66, 68, 69, and 72). These extend from 0.009% (West Ireland,
reference 56) to 0.97% (Italy, reference 61) and therefore likely
reflect a methodologic inconsistency. For example, if angle closure is
defined as “equal to or less than grade II” (61) rather than the more
accepted criterion requiring some degree of iridocorneal contact,
then ACG is going to be overdiagnosed greatly. Conversely,
considering the variable technique and subjective interpretation of
gonioscopy, ACG may be underdiagnosed. For example, we and
other investigators have shown that if angle examination is done in
 Correspondence
conditions of strong light in the examining room and/or slit lamp, an
otherwise appositionally closed angle can be misdiagnosed as
open.2,3 As another example, an examiner can mistakenly record
seeing the pigmented trabecular meshwork, where in reality what is
visualized is linear pigment deposition more anteriorly; angle closure
is thus missed and underdiagnosed (the true trabecular meshwork
can be revealed and this mistake can be avoided only when
employing dynamic corneal indentation with the gonio-lens).
Because, in some population studies, very few subjects are diag-
nosed with ACG, missing even a few cases might significantly skew
the reported rate. A small study by one of us seems to suggest that
published figures of 0.6% (reference 60) or 0.7% (reference 72) are
closer to the true prevalence rate.4
The answer awaits a modern prevalence study that, in addition
to incorporating good gonioscopic technique, includes objective
angle grading using an imaging device. In some studies, it has been
reported that when imaging devices are used to diagnose angle
closure, rates are higher compared with gonioscopy.3,5 Even with
the great respect we all hold for clinical examination, this would
provide objective measurement and diagnosis, similar to using a
laser cell flare meter for measurement and/or diagnosis in studies of
uveitis, or using OCT rather than slit-lamp examination in studies
of measurement and/or diagnosis of macular edema.
YANIV BARKANA, MD1,2
SYRIL DORAIRAJ, MD3
1
Glaucoma Unit, Department of Ophthalmology, Assaf Harofe Medical
Center, Zerifin, Israel; 2Department of Ophthalmology, Tel Aviv
University Medical School, Tel Aviv, Israel; 3Department of
Ophthalmology, Glaucoma, Anterior Segment Surgery, Mayo Clinic,
Jacksonville, Florida
Financial Disclosure(s): The authors have no proprietary or commercial
interest in any materials discussed in this article.
Correspondence:
Yaniv Barkana, MD, Assaf Harofe Medical Center, Department of
Ophthalmology, Beer Yaakov 70300, Israel. E-mail: yanivbarkana@
gmail.com.
References
1. Tham YC, Li X, Wong TY, et al. Global prevalence of glau-
coma and projections of glaucoma burden through 2040: a
systematic review and meta-analysis. Ophthalmology 2014;121:
2081–90.
2. Barkana Y, Dorairaj SK, Gerber Y, et al. Agreement be-
tween gonioscopy and ultrasound biomicroscopy in detecting
iridotrabecular apposition. Arch Ophthalmol 2007;125:
1331–5.
3. Mishima K, Tomidokoro A, Suramethakul P, et al. Irido-
trabecular contact observed using anterior segment three-
dimensional OCT in eyes with a shallow peripheral anterior
chamber. Invest Ophthalmol Vis Sci 2013;54:4628–35.
4. Barkana Y, Dekel I, Goldich Y, et al. Angle closure in
Caucasiansea pilot, general ophthalmology clinic-based study.
J Glaucoma 2012;21:337–41.
5. Sakata LM, Lavanya R, Friedman DS, et al. Comparison of
gonioscopy and anterior segment ocular coherence tomography
in detecting angle closure in different quadrants of the anterior
chamber angle. Ophthalmology 2008;115:769–74.
Author reply
Dear Editor:
We thank the authors for their valuable comments and suggestions.
We agree with the first comment that accurate determination of the
prevalence estimates of primary angle-closure glaucoma (PACG) in
non-Asian populations is challenging, particularly for North America,
Latin America, and Europe. This is mainly owing to the limited
PACG prevalence data available in these regions. We would like to
clarify that we included a total of 15 publications with PACG data
available from non-Asian populations in our systematic review as
opposed to 7 publications suggested by the authors (see Fig 2B).1
Nevertheless, we acknowledge that the difference in the definition
of anterior chamber angle closure across the included studies and
the subjective interpretation of gonioscopy might potentially result
in underdiagnosis or overdiagnosis of PACG cases across the
studies. Furthermore, we also agree with the authors that
misclassification of PACG cases, especially in populations of
smaller sample sizes,2e4 might significantly skew the reported
crude rate of PACG prevalence. Overall, these are valid concerns that
may further introduce variability to the estimate of PACG prevalence.
We were aware of these issues when we planned our study. To
minimize the impact of nonstandardized definition of angle closure
across different studies, we adopted the hierarchical Bayesian
approach to meta-analyze the prevalence of PACG. Overall, in this
hierarchical Bayesian approach, studies of smaller sample size and
larger credible intervals contributed lesser weight to the final pooled
estimation of PACG prevalence. Thus, in this meta-analysis, the
impact of those studies with potentially significant skewness in
PACG rates (in the event of misclassification) was mitigated to a
certain extent. In addition, as detailed in our manuscript, hierar-
chical Bayesian approach was able to borrow information across
other regions; this is especially useful for non-Asian regions (i.e.,
Europe, North America) with few PACG data. Having said this, we
acknowledge that the source of variability owing to non-
standardized angle closure definitions may not be entirely excluded.
Despite this limitation, our recently published findings provided the
most up-to-date estimations of PACG prevalence for different
world regions, and served as current best available evidence/refer-
ence for planning of public health strategies.
Finally, we appreciate the authors’ suggestion of incorporating
objective angle grading using anterior segmenteoptical coherence
tomography (AS-OCT) imaging for population-based studies. We
acknowledge that AS-OCT may be a useful complementary tool in
diagnosing closed anterior chamber angle, and may potentially
reduce the misclassification rates of PACG cases. Nevertheless, in
AS-OCTeacquired images, identification of scleral spur, which is
crucial for diagnosis of angle closure, remains a subjective mea-
sure.5 Hence, it should be noted that AS-OCT imaging may not
provide absolute objectivity in anterior chamber angle assessment.
In addition, the logistical feasibility of incorporating AS-OCT im-
aging for rural, population-based studies needs to be taken into
consideration.
YIH-CHUNG THAM, BSC, HONS1,2
CHING-YU CHENG, MD, PHD1,2,3
1
Singapore Eye Research Institute, Singapore National Eye Centre,
Singapore; 2Department of Ophthalmology, Yong Loo Lin School of
Medicine, National University of Singapore and National University
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