Subjective evaluation of visual acuity is not reliable to detect disease
activity in different exudative maculopathies
Hansjuergen Thomas Agostini
Received: 6 November 2017 /Revised: 3 May 2018 / Accepted: 23 May 2018
Springer-Verlag GmbH Germany, part of Springer Nature 2018
Background Patients with exudative maculopathies (neovascular age-related macular degeneration (nAMD), diabetic macular
edema (DME), and retinal vein occlusion (RVO)) are faced with a high burden of examinations and treatments. This study was
conceived to analyze the accuracy of a subjective evaluation of visual acuity (VA) and metamorphopsia to detect disease
reactivation, compared to morphological signs of reactivation assessed by means of SD-OCT.
Methods Retrospective study of 888 patients treated for nAMD (n = 638), DME (84), BRVO (110), and CRVO (56) was
conducted. Subjective evaluation of the patient at an examination (i.e., change of VA and/or metamorphopsia) was compared
to clinical evaluation of disease activity as assessed by SD-OCT. Sensitivity and specificity, negative and positive predictive
values (PPV/NPV) for detection of active disease were calculated. Factors associated with false-negative subjective evaluation
were analyzed by regression analysis.
Results The sensitivity of the subjective evaluation to detect disease reactivation was < 0.50 in all exudative maculopathies.
Sensitivity was increased to ≥ 0.60 by combining subjective worsening with loss of 1 line in the VA test in RVO, but not in DME
and nAMD. The specificity was > 0.85 in all patients. PPV was > 0.85 in patients with RVO. Regression analysis did not reveal
any factors that could reliably identify patient subgroups in which OCT could be omitted, though CRVO patients with a visual
acuity of < 0.3 logMAR had an odds ratio of 0.20 for false-negative subjective evaluation (p =0.009).
Conclusion The accuracy of subjective evaluation to discriminate disease activity in patients with different exudative
maculopathies was low and cannot substitute for frequent SD-OCT exams. Routinely assessed clinical parameters such as age,
visual acuity, or treatment experience were of no use to predict the validity of subjective evaluation of disease activity.
Trial registration This trial was registered at the DRKS (Deutsches Register Klinischer Studien, drks.de; No 00006851) prior to
the inclusion of the first patient.
The management of patients treated with intravitreal in-
jections for exudative maculopathy, such as neovascular
age-related macular degeneration (nAMD), diabetic mac-
ular edema (DME), myopic choroidal neovascularization
(mCNV), and edema in branch or central retinal vein
occlusion (BRVO, CRVO), requires a tremendous
amount of organization and resources. Using a standard
pro re nata treatment regimen, patients have to see a
specialist approximately every 4 weeks. SD-OCT is com-
monly accepted as an indispensable tool to evaluate dis-
ease activity and is recommended by ophthalmic socie-
ties in most countries. However, the cost of SD-OCT is
not generally covered by insurance companies in
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00417-018-4021-x) contains supplementary
material, which is available to authorized users.
* Christoph Ehlken
Eye Center, Medical Center, Faculty of Medicine,
Albert-Ludwigs-University, Killianstraße 5, 79106 Freiburg im
Center for Pulmonary Hypertension, Thoraxclinic at the University
Hospital Heidelberg, Röntgenstraße 1, 69126 Heidelberg, Germany
Department of Ophthalmology, Faculty of Medicine,
Christian-Albrechts-University, Arnold-Heller-Strasse 3,
24105 Kiel, Germany
Graefe's Archive for Clinical and Experimental Ophthalmology