Optimising subjective anterior eye grading precision

Marta Vianya-Estopa, Manbir Nagra, Arnold Cochrane, Neil Retallic, Dean Dunning, Louise Terry, Aoife Lloyd, James S Wolffsohn,

Research output: Contribution to journalArticlepeer-review


PURPOSE: To establish the optimum grading increment which ensured parity between practitioners while maximising clinical precision.

METHODS: Second year optometry students (n = 127, 19.5 ± 1.4 years, 55 % female) and qualified eye care practitioners (n = 61, 40.2 ± 14.8 years, 52 % female) had 30 s to grade each of bulbar, limbal and palpebral hyperaemia of the upper lid of 4 patients imaged live with a digital slit lamp under 16× magnification, diffuse illumination, with the image projected on a screen. The patients were presented in a randomised sequence 3 times in succession, during which the graders used the Efron printed grading scale once to the nearest 0.1 increment, once to nearest 0.5 increment and once to the nearest integer grade in a randomised order. Graders were masked to their previous responses.

RESULTS: For most grading conditions less than 20 % of clinicians showed a ≤0.1 difference in grade from the mean. In contrast, more than 50 % of the student graders and 40 % of experienced graders showed a difference in grade from the mean within 0.5 for all conditions under measurement. Student precision in grading was better with both 0.1 and 0.5 grading increments than grading to the nearest unit, except for limbal hyperaemia where they performed more accurately with 0.5 unit increment grading. Limbal grading precision was not affected by grading step increment for experienced practitioners, but 0.1 and 0.5 grading increments were both better than the 1.0 grading increment for bulbar hyperaemia and the 0.1 grading increment was better than the 0.5 grading increment and both were better than the 1.0 grading increment for palpebral hyperaemia.

CONCLUSION: Although narrower interval scales maximise the ability to detect smaller clinical changes, the grading increment should not exceed one standard deviation of the discrepancy between measurements. Therefore, 0.5 grading increments are recommended for subjective anterior eye physiology grading (limbal, bulbar and palpebral redness).

Original languageEnglish
Pages (from-to)489-492
Number of pages4
JournalContact Lens and Anterior Eye
Issue number5
Early online date23 Mar 2020
Publication statusPublished - Oct 2020

Bibliographical note

© 2020, Elsevier. Licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International http://creativecommons.org/licenses/by-nc-nd/4.0/


  • Eye-care practitioner
  • Grading
  • Hyperaemia
  • Scale increments
  • Student


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