Attitudes and Perceptions Toward Virtual Health in Eye Care During Coronavirus Disease 2019.

Purpose: To evaluate attitudes and perceptions toward virtual health (VH) and its usage among eye care providers before, during, and after the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: In April and May 2020, an online survey comprised of questions regarding past and current VH practices, as well as plans for future use was distributed among eye care providers nationwide. Results: Of the 117 eye care providers who completed the survey, 96.6% were not using VH before the COVID-19 pandemic. In contrast, 77.4% reported using VH during the pandemic. The majority of visits were for red eye (64.4%, n = 56) and ocular surface complaints (58.6%, n = 51). Examination components tested virtually varied, but most respondents felt these were at least "somewhat reliable." Almost half of respondents (45%) felt it was "very easy" or "somewhat easy" to implement VH and the majority (53.8%, n = 43) were able to get it up and running in under a week. The majority felt the transition to VH was positive (57.5%), however, only 50.4% (n = 53) of those providers planned to use VH regularly once able to see patients safely in clinic again. Conclusions: While the majority of U.S. eye care providers who responded were not using VH before the COVID-19 pandemic, just months into the U.S. outbreak, 77.4% were using VH in their daily practice. In general, providers used these platforms for urgent examinations, adnexal disease, and postoperative care most often. The majority felt the transition was a positive one, however, only half planned to continue regular use of VH once the pandemic ended.

Cataract surgery and intraocular pressure in glaucoma.

PURPOSE OF REVIEW: To review the current literature on the relationship between cataract extraction and intraocular pressure (IOP). RECENT FINDINGS: Cataract extraction can be an effective IOP lowering treatment for open and closed angle glaucoma as well as ocular hypertension. In comparative trials studying novel micro-invasive glaucoma surgeries in open angle glaucoma, the control group undergoing cataract extraction alone routinely achieved significant reductions in IOP and medication use postoperatively. Data from the Effectiveness in Angle Closure Glaucoma of Lens Extraction (EAGLE) trials have demonstrated that lens extraction is more effective at lowering IOP than peripheral iridotomy in patients with angle closure and should be considered as first line therapy. Additionally, patients in the ocular hypertension treatment study who underwent cataract extraction over the course of follow-up demonstrated significant IOP lowering sustained over 3 years. SUMMARY: Cataract extraction is an effective method to lower IOP in patients with glaucoma. Pressure lowering is more significant in eyes with narrow angles and those with higher baseline IOP levels. In eyes with angle closure, phacoemulsification alone can lower IOP, but when combined with GSL it may be even more effective. Recent large multicenter randomized trials have further elucidated the benefit of standalone cataract extraction to treat mild to moderate primary open angle glaucoma. Prospective and longitudinal studies that systematically investigate the variables that may influence degree and duration of IOP lowering post cataract extraction are lacking.

24-Hour Intraocular Pressure Control with Fixed-dose Combination Brinzolamide 1%/Brimonidine 0.2%: A Multicenter, Randomized Trial.

PURPOSE: To determine the intraocular pressure (IOP)-lowering effect of fixed-combination brinzolamide 1%/brimonidine 0.2% (BBFC) over a 24-hour period. DESIGN: Prospective, multicenter, double-masked, parallel-group clinical trial conducted at 16 academic and nonacademic sites in the United States. PARTICIPANTS: Subjects with open-angle glaucoma (OAG) or ocular hypertension (OHT) aged ≥18 years with mean baseline IOP measurements in at least 1 eye of ≥21 and <28 mmHg. METHODS: Duplicate mean pneumatonometer IOP measurements were collected every 2 hours over a 24-hour period in controlled light conditions in overnight facilities. Daytime (8 am-8 pm) and nocturnal (10 pm-6 am) IOP measurements were collected in a sitting or supine position, respectively. Baseline 24-hour IOP was measured in untreated subjects after a washout (up to 4 weeks) and eligibility phase. After the baseline visit, participants were randomized 1:1 to receive masked BBFC or vehicle, 1 drop 3 times daily (8 am, 3 pm, and 10 pm) for 4 weeks. At week 4, IOP measurements were repeated in both groups under the same conditions. MAIN OUTCOME MEASURE: Mean change from baseline in 24-hour IOP at week 4. RESULTS: Of 125 participants randomized, 123 (98%; BBFC, n = 62; vehicle, n = 61) completed the study. No subjects randomized to BBFC discontinued the study. At week 4, BBFC-treated eyes had significantly reduced mean 24-hour IOP vs. vehicle (least squares mean difference [95% confidence interval]: -2.5 [-3.3, -1.7]; P < 0.001); daytime (-3.4 [-4.3, -2.6]; P < 0.001) and nocturnal (-1.2 [-2.3, 0.0]; P = 0.053) reductions were observed. Mean change from baseline was significantly different between BBFC- and vehicle-treated eyes at all daytime points and 3 of 5 nocturnal time points (10 pm, 12 am, and 6 am; secondary end point). The frequency of adverse events was similar between treatment groups; in the BBFC arm, ocular hyperemia, corneal abrasion, and dysgeusia were the most frequently reported, consistent with events described in the drug label. CONCLUSIONS: This large, multicenter study of 24-hour IOP control with BBFC met its primary end point; BBFC demonstrated significantly superior 24-hour IOP-lowering efficacy versus vehicle after 4 weeks of 3-times-daily treatment in subjects with OAG or OHT.

Current opinion in ophthalmology: novel glaucoma devices in the pipeline.

PURPOSE OF REVIEW: Adherence to chronic use of topical intraocular pressure (IOP) lowering medications is a fundamental barrier to successful, long-term control in patients suffering from glaucoma. This has fueled innovation to create new vehicles for drug administration, new drug formulations with enhanced bioavailability, and minimally invasive glaucoma surgeries (MIGS) with improved risk-benefit profiles to enhance sustained IOP control. The present article is an overview of novel devices in the pipeline. RECENT FINDINGS: Several new devices that promise to deliver sustained drug therapy and reduce dependence on daily patient adherence are currently being vetted through clinical trials. In addition, the pipeline for new MIGS devices that target sustained IOP control continues to grow. SUMMARY: Alternative drug delivery approaches and novel MIGS devices broaden the treatment options for patients with glaucoma. This will allow the clinician to customize treatment by selecting specific approaches based on each patient's individual needs and coexisting ocular pathologies. Additional comprehensive, large-scale, clinical studies will help define the role that these options hold in a constantly evolving treatment paradigm.

Third harmonic generation microscopy of a mouse retina.

PURPOSE: To demonstrate lipid-specific imaging of the retina through the use of third harmonic generation (THG), a multiphoton microscopic technique in which tissue contrast is generated from optical inhomogeneities. METHODS: A custom fiber laser and multiphoton microscope was constructed and optimized for simultaneous two-photon autofluorescence (TPAF) and THG retinal imaging. Imaging was performed using fixed-frozen sections of mouse eyes without the use of exogenous fluorescent dyes. In parallel experiments, a fluorescent nuclear stain was used to verify the location of the retinal cell nuclei. RESULTS: Simultaneous THG and TPAF images revealed all retinal layers with subcellular resolution. In BALB/c strains, the THG signal stems from the lipidic organelles of the cellular and nuclear membranes. In the C57BL/6 strain, the THG signal from the RPE cells originates from the pigmented granules. CONCLUSIONS: THG microscopy can be used to image structures of the mouse retina using contrast inherent to the tissue and without the use of a fluorescent dye or exogenously expressed recombinant protein.

Ability of Bottle Cap Color to Facilitate Accurate Patient-Physician Communication Regarding Medication Identity in Patients with Glaucoma.

PURPOSE: To determine the accuracy of patient-physician communication regarding topical ophthalmic medication use based on bottle cap color, particularly among individuals who may have acquired color vision deficiency from glaucoma. DESIGN: Cross-sectional, clinical study. PARTICIPANTS: Patients aged ≥18 years with primary open-angle, primary angle-closure, pseudoexfoliation, or pigment dispersion glaucoma, bilateral visual acuity of ≥20/400, and no concurrent conditions that may affect color vision. METHODS: A total of 100 patients provided color descriptions of 11 distinct medication bottle caps. Color descriptors were then presented to 3 physicians. Physicians matched each color descriptor to the medication they thought the descriptor was describing. MAIN OUTCOME MEASURES: Frequency of patient-physician agreement, occurring when all 3 physicians accurately matched the color descriptor to the correct medication. Multivariate regression models evaluated whether patient-physician agreement decreased with degree of better-eye visual field (VF) damage, color descriptor heterogeneity, or color vision deficiency, as determined by the Hardy-Rand-Rittler (HRR) score and Lanthony D15 color confusion index (D15 CCI). RESULTS: Subjects had a mean age of 69 (±11) years, with VF mean deviation of -4.7 (±6.0) and -10.9 (±8.4) decibels (dB) in the better- and worse-seeing eyes, respectively. Patients produced 102 unique color descriptors to describe the colors of the 11 bottle caps. Among individual patients, the mean number of medications demonstrating agreement was 6.1/11 (55.5%). Agreement was less than 15% for 4 medications (prednisolone acetate [generic], betaxolol HCl [Betoptic; Alcon Laboratories Inc., Fort Worth, TX], brinzolamide/brimonidine [Simbrinza; Alcon Laboratories Inc.], and latanoprost [Xalatan; Pfizer, Inc., New York, NY]). Lower HRR scores and higher D15 CCI (both indicating worse color vision) were associated with greater VF damage (P < 0.001). Extent of color vision deficiency and color descriptor heterogeneity significantly predicted agreement in multivariate models (odds of agreement = 0.90 per 1 point decrement in HRR score, P < 0.001; odds of agreement = 0.30 for medications exhibiting high heterogeneity [≥11 descriptors], P = 0.007). CONCLUSIONS: Physician understanding of patient medication use based solely on bottle cap color is frequently incorrect, particularly in patients with glaucoma who may have color vision deficiency. Errors based on communication using bottle cap color alone may be common and could lead to confusion and harm.

Predictors of adherence to glaucoma treatment in a multisite study.

BACKGROUND: Poor adherence hinders glaucoma treatment. Studies have identified demographic and clinical predictors of adherence but fewer psychological variables. PURPOSE: We examined predictors from four health behavior theories and past research. METHODS: In the baseline phase of a three-site adherence study, before any intervention, 201 participants used electronic Medication Event Monitoring System (MEMS) bottles to monitor eyedrop use for 2 months, and completed questionnaires including self-reported adherence. RESULTS: MEMS showed 79% adherence and self-report 94% (0.5-1.5 missed weekly doses), but they correlated only r(s) = 0.31. Self-efficacy, motivation, dose frequency, and nonminority race/ethnicity predicted 35% of variance in MEMS. Cues to action, self-efficacy, and intention predicted 20% of variance in self-reported adherence. CONCLUSIONS: Self-efficacy, motivation, intention, cues to action, dose frequency, and race/ethnicity each independently predicted adherence. Predictors from all theories were supported in bivariate analyses, but additional study is needed. Researchers and clinicians should consider psychological predictors of adherence. (ClinicalTrials.gov ID# NCT01409421.).

Aflibercept for the treatment of neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a potentially blinding disease associated with ocular ischaemia. Use of an anti-vascular endothelial growth factor agent has been reported as a treatment option for NVG. The purpose of this study was to investigate initial results regarding the treatment of NVG with intravitreal aflibercept. DESIGN: This study employed a prospective, interventional case series study design. PARTICIPANTS: Patients with newly diagnosed stage 1 or 2 neovascular glaucoma were eligible to participate in this study. METHODS: Four patients with newly diagnosed stage 1 or 2 NVG were treated with intravitreal aflibercept at the time of diagnosis, with planned repeat injection at 4 weeks, 8 weeks and then every 8 weeks thereafter up until 52 weeks after study initiation. MAIN OUTCOME MEASURES: Primary outcomes were regression of neovascularization of the iris and angle (NVI, NVA). Secondary outcome measurements included visual acuity and intraocular pressure (IOP). RESULTS: Intravitreal aflibercept resulted in rapid regression of NVI and NVA. IOP was stable or reduced in all patients at the 52-week study visit. CONCLUSIONS: These results suggest that intravitreal aflibercept may be an effective treatment for stage 1 and 2 NVG, resulting in rapid and sustained regression of NVI and NVA as well as control of IOP. Further research is needed to determine the full duration of effect and the optimal dose and timing of administration.

Evaluation of stability and capsular bag opacification of a new foldable adjustable intraocular lens.

BACKGROUND: Incorrect lens power remains one of the most common reasons for intraocular lens explantation/exchange. We evaluated stability and effect on capsular bag opacification of a new foldable modular lens system, with a base component and an optic component in rabbit eyes. METHODS: Bilateral phacoemulsification was performed on six rabbits; one eye received the test lens (Harmoni Modular Lens, ClarVista Medical), whereas the other received a single-piece hydrophobic acrylic control lens (SA60AT, Alcon). Slit-lamp examinations were performed at postoperative weeks 1, 2, 3, 4 and 6. All rabbits were sacrificed at week 6. After enucleation, the eyes were examined grossly from the Miyake-Apple view. Following, all globes were sectioned and processed for histopathological examination. RESULTS: The modular lens was stable in all six rabbits. Uveal biocompatibility was similar to or better in the test eyes when compared with control eyes up to 6 weeks postoperatively. Overall, capsular bag opacification was found to be significantly lower in the test eyes when compared with control eyes. At the 6-week gross examination, central posterior capsule opacification was scored as 0.58 ± 0.73 in the test group, and as 3.00 ± 1.26 in the control group (paired two samples for means t-test; two-tail P = 0.005). CONCLUSIONS: The Harmoni Modular system remains stable within the capsular bag after implantation. Due to the design of the base component featuring long loops, along with peripheral anterior and posterior square edges, the lens appeared to prevent overall capsular bag opacification in the rabbit model.

The link between intravitreal antivascular endothelial growth factor injections and glaucoma.

PURPOSE OF REVIEW: To summarize the reports of both transient and sustained elevation in intraocular pressure (IOP) associated with intravitreal injections of antivascular endothelial growth factor (anti-VEGF) agents and to review the possible mechanisms for these findings. RECENT FINDINGS: Transient elevation in IOP is common after intravitreal injection of anti-VEGF agents. Sustained IOP elevation is less commonly seen but can require medical and/or surgical intervention. The mechanism for sustained IOP elevation is not well understood but has been attributed to trabecular meshwork injury from repeated injections, a potential toxic or inflammatory reaction after exposure to the biologic agents and/or vehicle, or mechanical blockade of the trabecular meshwork by protein aggregates or contaminant particles associated with packaging and injection techniques, among other potential causes. SUMMARY: Intravitreal anti-VEGF injections are commonly used to treat neovascular diseases of the eye. Although they have a favorable side-effect profile, their use can be associated with both transient and sustained elevation in IOP. Further research is necessary to determine the cause of these findings.

Evaluating the strengths and limitations of multimodal ChatGPT-4 in detecting glaucoma using fundus images.

Overview: This study evaluates the diagnostic accuracy of a multimodal large language model (LLM), ChatGPT-4, in recognizing glaucoma using color fundus photographs (CFPs) with a benchmark dataset and without prior training or fine tuning. Methods: The publicly accessible Retinal Fundus Glaucoma Challenge "REFUGE" dataset was utilized for analyses. The input data consisted of the entire 400 image testing set. The task involved classifying fundus images into either 'Likely Glaucomatous' or 'Likely Non-Glaucomatous'. We constructed a confusion matrix to visualize the results of predictions from ChatGPT-4, focusing on accuracy of binary classifications (glaucoma vs non-glaucoma). Results: ChatGPT-4 demonstrated an accuracy of 90% with a 95% confidence interval (CI) of 87.06%-92.94%. The sensitivity was found to be 50% (95% CI: 34.51%-65.49%), while the specificity was 94.44% (95% CI: 92.08%-96.81%). The precision was recorded at 50% (95% CI: 34.51%-65.49%), and the F1 Score was 0.50. Conclusion: ChatGPT-4 achieved relatively high diagnostic accuracy without prior fine tuning on CFPs. Considering the scarcity of data in specialized medical fields, including ophthalmology, the use of advanced AI techniques, such as LLMs, might require less data for training compared to other forms of AI with potential savings in time and financial resources. It may also pave the way for the development of innovative tools to support specialized medical care, particularly those dependent on multimodal data for diagnosis and follow-up, irrespective of resource constraints.

Predicting Glaucoma Before Onset Using a Large Language Model Chatbot.

PURPOSE: To investigate the capability of ChatGPT for forecasting the conversion from ocular hypertension (OHT) to glaucoma based on the Ocular Hypertension Treatment Study (OHTS). DESIGN: Retrospective case-control study. PARTICIPANTS: A total of 3008 eyes of 1504 subjects from the OHTS were included in the study. METHODS: We selected demographic, clinical, ocular, optic nerve head, and visual field (VF) parameters 1 year before glaucoma development from the OHTS participants. Subsequently, we developed queries by converting tabular parameters into textual format based on both eyes of all participants. We used the ChatGPT application program interface (API) to automatically perform ChatGPT prompting for all subjects. We then investigated whether ChatGPT can accurately forecast conversion from OHT to glaucoma based on various objective metrics. MAIN OUTCOME MEASURE: Accuracy, area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and weighted F1 score. RESULTS: ChatGPT4.0 demonstrated an accuracy of 75%, AUC of 0.67, sensitivity of 56%, specificity of 78%, and weighted F1 score of 0.77 in predicting conversion to glaucoma 1 year before onset. ChatGPT3.5 provided an accuracy of 61%, AUC of 0.62, sensitivity of 64%, specificity of 59%, and weighted F1 score of 0.63 in predicting conversion to glaucoma 1 year before onset. CONCLUSIONS: The performance of ChatGPT4.0 in forecasting development of glaucoma 1 year before onset was reasonable. The overall performance of ChatGPT4.0 was consistently higher than ChatGPT3.5. Large language models (LLMs) hold great promise for augmenting glaucoma research capabilities and enhancing clinical care. Future efforts in creating ophthalmology-specific LLMs that leverage multimodal data in combination with active learning may lead to more useful integration with clinical practice and deserve further investigations.

In vitro effects of verteporfin on ocular cells.

PURPOSE: Photodynamic therapy (PDT) laser light in conjunction with the benzoporphyrin derivative verteporfin is a current clinical treatment for choroidal vascular diseases such as age-related macular degeneration. The aim of this study was to examine the effects of PDT laser-activated and inactive verteporfin on various cultured ocular cells. METHODS: Primary human scleral fibroblasts (hFibro), primary human trabecular meshwork (TM) cells (hTMC), primary porcine TM cells (pTMC), and a human retinal pigment epithelial cell line (ARPE-19 cells) were treated with verteporfin with and without activation by PDT laser. Cell viability was determined according to mitochondrial enzyme activity (3-(4,5- dimethyl-2-thiazoyl)-2,5-diphenyl-2H-tetrazolium bromide assay). RESULTS: PDT laser treatment alone was insufficient to cause significant cell death in any of the cell types tested. Twenty-four-hour exposure to inactive verteporfin (without PDT laser) caused a dose-dependent decrease in cell viability in hFibro and hTMC, and to a lesser extent ARPE-19 cells. Verteporfin (0.5 µg/ml) without PDT laser activation caused a slight but statistically insignificant reduction in cell viability in hFibro (81.5% ± 19.3%), pTMC (82.9% ± 6.7%), hTMC (80.3% ± 7.7%), and ARPE-19 cells (84.5% ± 14.9%). Verteporfin (0.5 µg/ml) plus 50 µJ/cm(2) PDT laser treatment significantly decreased viability in hFibro (13.5% ± 3.3%), pTMC (7.1% ± 1.5%), hTMC (11.1% ± 5.2%), and ARPE-19 (44.5% ± 7.8%). Similar results were obtained in cells where verteporfin incubation was followed by washout before PDT laser, indicating that verteporfin is internalized by the studied cell lines. CONCLUSIONS: PDT laser-induced cell death was obtained with coincubation of verteporfin or preincubation followed by washout. These results suggest a potential future use of PDT therapy for selective in vivo removal of targeted ocular cells beyond the current use for destroying vascular endothelial cells.

Ethyl pyruvate treatment mitigates oxidative stress damage in cultured trabecular meshwork cells.

PURPOSE: Oxidative stress plays a key role in the pathophysiology of glaucoma. This study was designed to assess ethyl pyruvate (EP) as a novel antioxidative agent in cultured human trabecular meshwork (hTM) cells. METHODS: Primary hTM cells were cultured on collagen matrices. Tolerance to EP was assessed at various concentrations using fluorescent vital dyes (live/dead) and metabolic (1-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assays. After the candidate doses were identified, cells received either preincubation with EP before hydrogen peroxide stressing or pre- and coincubation with EP before and during stressing. Live/dead and metabolic activity assays were used to quantify oxidative damage. RESULTS: Cultured hTM cells were well tolerant of EP concentrations at or below 10 mM while higher doses showed significant levels of cytotoxicity. In the peroxide stress assays, samples that received pre- and cotreatment with all concentrations of EP showed significantly increased cell survival and maintenance of metabolic activity. However, samples that received only pretreatment did not show a significant increase in survival rates and lost nearly all metabolic activity after peroxide-induced stressing. CONCLUSIONS: This work suggests that EP is a potent antioxidant that is well tolerated by hTM cells; however, EP's potential as a therapeutic agent for glaucoma is limited by its inability to enhance endogenous antioxidant capacity. A continuous drug delivery system may be needed to realize the full therapeutic potential of EP for treatment of glaucoma.

The effects of aflibercept on the viability and metabolism of ocular cells in vitro.

PURPOSE: To investigate the effects of the vascular endothelial growth factor-neutralizing agent aflibercept on primary cultures of human trabecular meshwork cells (hTMC), human scleral fibroblasts (hFibro), and a retinal pigment epithelial cell line (ARPE-19). METHODS: Various concentrations of aflibercept were incubated with confluent cell cultures for 24 hours. Ranibizumab was used as an active control for comparison. Assays of cellular metabolism (MTT assay) and cell viability (calcein dye uptake) were performed. RESULTS: Compared with untreated controls (100% live), a 24-hour exposure to 1 mg/mL aflibercept had no significant effect on cell viability in hTMC (100.1 ± 1.7%), hFibro (102.4 ± 2.4%), or ARPE-19 (99.3 ± 3.9%) cells. Aflibercept vehicle controls also had no detrimental effect. Aflibercept (1 mg/mL) had no statistically significant effect on metabolic activity in hTMC (84.3 ± 10.2%), hFibro (102.7 ± 4.3%), and ARPE-19 (104.6 ± 12.6%) cells. When compared side-by-side in ARPE-19 cells, aflibercept and the anti-vascular endothelial growth factor agent ranibizumab had no toxicity at the highest concentration tested (1 mg/mL). CONCLUSION: The authors' data reveal that concentrations of aflibercept in the range expected to occur in the human vitreous after intraocular injection are not harmful in an in vitro cell assay.

Combined Phacoemulsification and STREAMLINE Surgical System Canal of Schlemm Transluminal Dilation in Eyes of Hispanic Patients with Mild to Moderate Glaucoma.

Purpose: To characterize clinical outcomes of transluminal dilation of the canal of Schlemm using the STREAMLINE Surgical System combined with phacoemulsification in eyes of Hispanic patients diagnosed with mild to moderate primary open-angle glaucoma. Methods: This was a prospective analysis of all cases performed and followed up to 12 months. All eyes underwent medication washout preoperatively. Reduction in intraocular pressure (IOP) from unmedicated baseline, as well as medications from pre-washout baseline, were analyzed at postoperative Day 1, Week 1, and Months 1, 3, 6, 9, and 12. Results: All 37 patients were Hispanic, 83.8% were female, and mean (standard deviation) age was 66.0 (10.5) years. Mean medicated preoperative IOP was 16.9 (3.2) mmHg using a mean of 2.1 (0.9) medications, unmedicated baseline IOP (after washout) was 23.2 (2.3) mmHg, and mean IOP at every postoperative study visit was significantly lower (p<0.0002). Mean IOP from month 1 through the first postoperative year ranged from 14.7-16.2 mmHg, representing a reduction of 7.0-8.5 mmHg (30.7-36.5%). At month 12, 80% of all eyes (28/35) and 77.8% of medication-free eyes (14/18) had IOP reduction ≥20% from unmedicated baseline, and 51.4% of eyes (18/35) were medication-free. Mean medication use was significantly reduced (by 59.9-74.6%, p<0.0001) at every postoperative study visit. The only adverse event occurring in >1 eye was high IOP (n=4) which was responsive to topical medical therapy; no adverse events were attributed to the transluminal dilation procedure. Conclusion: Transluminal dilation of the canal of Schlemm using the STREAMLINE Surgical System combined with phacoemulsification safely and effectively reduced both IOP and dependence on IOP-lowering medications in a Hispanic population diagnosed with POAG and should be considered at the time of phacoemulsification in Hispanic patients who have a need for IOP reduction, medication reduction, or both.

Preclinical Investigation of Ab Interno Goniotomy Using Three Different Techniques.

Purpose: To evaluate incisional or excisional tissue-level effects of ab interno goniotomy techniques on human trabecular meshwork (TM). Methods: The TM from human cadaveric corneal rim tissue was treated using three devices: (1) Kahook Dual Blade (KDB) GLIDE, (2) iAccess, and (3) SION. Two human corneal rims were used for each of the iAccess and SION devices and one with the KDB GLIDE, with 360 degrees of TM treated in each case. Sections were then prepared for analysis and comparison between devices. Tissue samples underwent standard histologic processing with H&E stain, followed by comparative analyses. Results: Areas treated with the KDB GLIDE device resulted in nearly complete excision of TM overlying the canal of Schlemm without injury to surrounding tissues. The iAccess device can be used as a focal trephine to create holes or dragged for TM disruption. When used to create holes, iAccess punched through the full thickness of the TM and also disrupted the anterior scleral tissue. It caused some incisional openings through the TM but with significant leaflets remaining and minimal true "hole-punch" effect. When the device tip was dragged, iAccess incised the TM and left debris behind with little, if any, excision of tissue. SION led to both incision and excision of TM with incision predominating over excision. Conclusion: The various methods evaluated to perform ab interno goniotomy resulted in varying degrees of TM incision or excision. Only the KDB GLIDE device resulted in reliable excision of TM, while the other devices produced incision or minimal excision of tissue with residual leaflets and debris. Use of iAccess resulted in focal disruption of the anterior scleral wall. Because incisional approaches that leave longer residual leaflets may be more prone to fibrosis and closure compared to excisional treatments, clinical correlation will be necessary to better understand the significance of these findings with respect to relative effectiveness of intraocular pressure lowering in eyes with glaucoma.

Artificial Intelligence and Glaucoma: Going Back to Basics.

There has been a recent surge in the number of publications centered on the use of artificial intelligence (AI) to diagnose various systemic diseases. The Food and Drug Administration has approved several algorithms for use in clinical practice. In ophthalmology, most advances in AI relate to diabetic retinopathy, which is a disease process with agreed upon diagnostic and classification criteria. However, this is not the case for glaucoma, which is a relatively complex disease without agreed-upon diagnostic criteria. Moreover, currently available public datasets that focus on glaucoma have inconstant label quality, further complicating attempts at training AI algorithms efficiently. In this perspective paper, we discuss specific details related to developing AI models for glaucoma and suggest potential steps to overcome current limitations.

The Use of ChatGPT to Assist in Diagnosing Glaucoma Based on Clinical Case Reports.

INTRODUCTION: The purpose of this study was to evaluate the capabilities of large language models such as Chat Generative Pretrained Transformer (ChatGPT) to diagnose glaucoma based on specific clinical case descriptions with comparison to the performance of senior ophthalmology resident trainees. METHODS: We selected 11 cases with primary and secondary glaucoma from a publicly accessible online database of case reports. A total of four cases had primary glaucoma including open-angle, juvenile, normal-tension, and angle-closure glaucoma, while seven cases had secondary glaucoma including pseudo-exfoliation, pigment dispersion glaucoma, glaucomatocyclitic crisis, aphakic, neovascular, aqueous misdirection, and inflammatory glaucoma. We input the text of each case detail into ChatGPT and asked for provisional and differential diagnoses. We then presented the details of 11 cases to three senior ophthalmology residents and recorded their provisional and differential diagnoses. We finally evaluated the responses based on the correct diagnoses and evaluated agreements. RESULTS: The provisional diagnosis based on ChatGPT was correct in eight out of 11 (72.7%) cases and three ophthalmology residents were correct in six (54.5%), eight (72.7%), and eight (72.7%) cases, respectively. The agreement between ChatGPT and the first, second, and third ophthalmology residents were 9, 7, and 7, respectively. CONCLUSIONS: The accuracy of ChatGPT in diagnosing patients with primary and secondary glaucoma, using specific case examples, was similar or better than senior ophthalmology residents. With further development, ChatGPT may have the potential to be used in clinical care settings, such as primary care offices, for triaging and in eye care clinical practices to provide objective and quick diagnoses of patients with glaucoma.

ChatGPT Assisting Diagnosis of Neuro-ophthalmology Diseases Based on Case Reports.

Purpose: To evaluate the efficiency of large language models (LLMs) including ChatGPT to assist in diagnosing neuro-ophthalmic diseases based on case reports. Design: Prospective study. Subjects or Participants: We selected 22 different case reports of neuro-ophthalmic diseases from a publicly available online database. These cases included a wide range of chronic and acute diseases that are commonly seen by neuro-ophthalmic sub-specialists. Methods: We inserted the text from each case as a new prompt into both ChatGPT v3.5 and ChatGPT Plus v4.0 and asked for the most probable diagnosis. We then presented the exact information to two neuro-ophthalmologists and recorded their diagnoses followed by comparison to responses from both versions of ChatGPT. Main Outcome Measures: Diagnostic accuracy in terms of number of correctly diagnosed cases among diagnoses. Results: ChatGPT v3.5, ChatGPT Plus v4.0, and the two neuro-ophthalmologists were correct in 13 (59%), 18 (82%), 19 (86%), and 19 (86%) out of 22 cases, respectively. The agreement between the various diagnostic sources were as follows: ChatGPT v3.5 and ChatGPT Plus v4.0, 13 (59%); ChatGPT v3.5 and the first neuro-ophthalmologist, 12 (55%); ChatGPT v3.5 and the second neuro-ophthalmologist, 12 (55%); ChatGPT Plus v4.0 and the first neuro-ophthalmologist, 17 (77%); ChatGPT Plus v4.0 and the second neuro-ophthalmologist, 16 (73%); and first and second neuro-ophthalmologists 17 (17%). Conclusions: The accuracy of ChatGPT v3.5 and ChatGPT Plus v4.0 in diagnosing patients with neuro-ophthalmic diseases was 59% and 82%, respectively. With further development, ChatGPT Plus v4.0 may have potential to be used in clinical care settings to assist clinicians in providing quick, accurate diagnoses of patients in neuro-ophthalmology. The applicability of using LLMs like ChatGPT in clinical settings that lack access to subspeciality trained neuro-ophthalmologists deserves further research.