Using Natural Language Processing to Identify Different Lens Pathology in Electronic Health Records.

PURPOSE: Nearly all published ophthalmology-related Big Data studies rely exclusively on International Classification of Diseases (ICD) billing codes to identify patients with particular ocular conditions. However, inaccurate or nonspecific codes may be used. We assessed whether natural language processing (NLP), as an alternative approach, could more accurately identify lens pathology. DESIGN: Database study comparing the accuracy of NLP versus ICD billing codes to properly identify lens pathology. METHODS: We developed an NLP algorithm capable of searching free-text lens exam data in the electronic health record (EHR) to identify the type(s) of cataract present, cataract density, presence of intraocular lenses, and other lens pathology. We applied our algorithm to 17.5 million lens exam records in the Sight Outcomes Research Collaborative (SOURCE) repository. We selected 4314 unique lens-exam entries and asked 11 clinicians to assess whether all pathology present in the entries had been correctly identified in the NLP algorithm output. The algorithm's sensitivity at accurately identifying lens pathology was compared with that of the ICD codes. RESULTS: The NLP algorithm correctly identified all lens pathology present in 4104 of the 4314 lens-exam entries (95.1%). For less common lens pathology, algorithm findings were corroborated by reviewing clinicians for 100% of mentions of pseudoexfoliation material and 99.7% for phimosis, subluxation, and synechia. Sensitivity at identifying lens pathology was better for NLP (0.98 [0.96-0.99] than for billing codes (0.49 [0.46-0.53]). CONCLUSIONS: Our NLP algorithm identifies and classifies lens abnormalities routinely documented by eye-care professionals with high accuracy. Such algorithms will help researchers to properly identify and classify ocular pathology, broadening the scope of feasible research using real-world data.

A Systematic Analysis of the Impact of an Ambulatory Ophthalmology Urgent Care Clinic.

Importance A same-day ophthalmic urgent care clinic can provide efficient eye care, a rich educational environment, and can improve patient experience. Objective The aim of this study was to systematically evaluate volume, financial impact, care metrics, and the breadth of pathology of urgent new patient encounters based on their site of initial presentation. Design, Setting, and Participants A retrospective analysis was performed on consecutive urgent new patient evaluations in our same-day triage clinic at the Henkind Eye Institute at Montefiore Medical Center between February 2019 and January 2020. The cohort of patients who presented directly to this urgent care clinic were referred to as the "TRIAGE" group. Patients who initially presented to an emergency department (ED), and were subsequently referred to our triage clinic, are referred to as the "ED + TRIAGE" group. Main Outcomes and Measures Visits were evaluated on a variety of metrics, including diagnosis, duration, charge, cost, and revenue. Furthermore, return to the ED or inpatient admission was documented. Results Of 3,482 visits analyzed, 2,538 (72.9%) were in the "TRIAGE" group. Common presenting diagnoses were ocular surface disease ( n = 486, 19.1%), trauma ( n = 342, 13.5%; most commonly surface abrasion n = 195, 7.7%), and infectious conjunctivitis ( n = 304, 12.0%). Patients in the "TRIAGE" group, on average, were seen 184.6% faster (158.2 vs. 450.2 minutes) than patients in the "ED + TRIAGE" group ( p < 0.001). The "ED + TRIAGE" group were furthermore found to generate 442.1% higher charges ($870.20 vs. 4717.70) and were associated with 175.1% higher cost ($908.80 vs. 330.40) per patient. The hospital was found to save money when noncommercially insured patients with ophthalmic complaints presented to the triage clinic instead of the ED. Patients seen in the triage clinic had a low rate of readmission to the ED ( n = 42, 1.2%). Conclusions and Relevance A same-day ophthalmology triage clinic provides efficient care, while providing a rich learning environment for residents. Less wait time with direct access to subspecialist care can help improve quality, outcome, and satisfaction metrics.

The Relationship Between Corneal Biomechanics and Intraocular Pressure Dynamics in Patients Undergoing Intravitreal Injection.

PRECIS: A higher "corneal resistance factor" (CRF) was associated with greater intraocular pressure (IOP) elevation after intravitreal injection of bevacizumab. Both higher "corneal hysteresis" (CH) and CRF were associated with more rapid IOP recovery postinjection. PURPOSE: The purpose of this study was to evaluate the relationship between measurable corneal biomechanical properties and acute IOP elevation after rapid intraocular volume expansion from the routine intravitreal injection. MATERIALS AND METHODS: A total of 100 patients necessitating unilateral intravitreal injection with 0.05 mL of bevacizumab for retinal pathology were analyzed before injection with Goldmann Applanation Tonometry to measure IOP, Ocular Response Analyzer (ORA) to measure corneal biomechanical properties, and optical biometry to calculate globe measurements. IOP and ORA were measured again within 5 minutes of the injection and then IOP measurements were taken every 10 minutes until the IOP was ≤150% of the preinjection IOP. Linear regression and logistic regression were used to test variables associated with acute IOP increase. A Cox proportional hazard model accounting for preinjection IOP and postinjection IOP was used to test the effect of CH or CRF on the time required to return to 150% of baseline IOP. RESULTS: Higher CRF was associated with greater immediate postinjection IOP (P=0.026) elevation. A preinjection IOP>15.5 mm Hg moderately predicted postinjection IOP≥35 mm Hg (area under the receiver operating characteristics curve=0.74). A preinjection IOP>18.5 mm Hg combined with CH poorly predicted postinjection IOP>50 mm Hg (area under the receiver operating characteristics curve=0.67). A higher CH [hazard ratio (HR)=1.24; 95% confidence interval (CI)=1.08-1.42; P=0.002] and preinjection IOP (HR=1.16; 95% CI=1.09-1.22; P<0.001), along with a lower immediate postinjection IOP (HR=0.93; 95% CI=0.90-0.95; P<0.001), were each independently associated with quicker IOP recovery postinjection. Similar results were seen in the Cox model examining CRF and IOP recovery. CONCLUSIONS: Higher CRF and preinjection IOP were independently associated with greater postinjection IOP elevations. ORA metrics did not greatly strengthen the prediction of patients who would have postinjection IOP>50 mm Hg. Higher CH and CRF were associated with faster IOP recovery after intravitreal injection, demonstrating the dynamic relationship between ocular biomechanical properties and aqueous outflow pathways.

Rare Optic Neuropathy in a Jamaican Couple Linked to Cassava Root Consumption.

We report central visual loss with selective papillomacular bundle damage in a Jamaican couple, husband and wife, with long-term cassava root consumption. The two cases presented independently with gradual central visual loss. Examination revealed bilateral temporal pallor of the optic nerve head and automated static perimetry demonstrated a central or caecocentral scotoma in each patient. Optical coherence tomography findings are described. The only mutual risk factor, reported independently, was long-term cassava consumption. Cessation of cassava intake and vitamin supplementation resulted in partial recovery of visual function. As thiocyanate levels in urine were not measured, the aetiology in these patients is not definitively confirmed, but chronic cassava consumption should be considered in similar cases as a rare cause of potentially reversible optic neuropathy.

Revisiting Ciliary Muscle Tendons and Their Connections With the Trabecular Meshwork by Two Photon Excitation Microscopic Imaging.

PURPOSE: To elucidate the anatomy of the trabecular meshwork (TM) and its connection to ciliary muscle (CM) tendons with two photon excitation microscopic (TPEM) imaging. METHODS: The human aqueous outflow pathway was imaged in an unfixed and nonembeded state by using an inverted TPEM. Laser (Ti:Sapphire) was tuned at 850 nm for emission. Backscatter signals of second harmonic generation (SHG) and autofluorescence (AF) were collected through 425/30-nm and 525/45 emission filters, respectively. Multiple, consecutive, and overlapping image stacks (z-stacks) were acquired to generate three-dimensional data sets. RESULTS: Collagen and elastin structures of the TM were successfully visualized with TPEM. The TM and CM tendons were found to contain both collagen and elastin fibers. What appears to be juxtacanalicular tissue (JCT) was identified by its honeycomb-like appearance in AF images. Tracing CM tendons from their origins and to their insertions revealed that elastin fibers of CM tendons were connected to the elastin network within the trabecular lamellae. The CM tendons converged or diverged along their course, forming intricate networks with the TM. The CM tendon fiber density varied depending on its location within the aqueous outflow pathway with tendons near the JCT found to be the most dense, and in a fine-tooth comb arrangement. CONCLUSIONS: By using TPEM imaging, new details of the human aqueous outflow pathway were elucidated. This high-resolution imaging technique revealed the intricate interconnections between the TM and CM tendons.

The differential pupillary response to 2.5% phenylephrine in patients taking tamsulosin.

PURPOSE: To determine if a pharmacological test could be developed to determine iris dilator dysfunction in patients taking tamsulosin. METHODS: Patients taking tamsulosin and controls were recruited from the Urology and Ophthalmology clinics at the Montefiore Medical Center. The patient's right eye (OD) was dilated with phenylephrine hydrochloride 2.5% and tropicamide 1%. The patient's left eye (OS) was dilated with tropicamide 1% alone. Forty minutes after dilation, pupillary diameter was measured in both eyes. RESULTS: Thirty-eight tamsulosin subjects and 43 controls met the inclusion criteria for the study. The tamsulosin-treated patients dilated less with phenylephrine than controls (0.61±0.4 vs. 1.10±0.45 mm, respectively P<0.001). Receiver operating characteristic curves comparing maximal pupillary dilation versus differential pupillary dilation in tamsulosin patients relative to controls shows a greater area under the curve for differential dilation (0.8 vs. 0.6, respectively). A correlation between smooth muscle dysfunction and length of time on tamsulosin was observed. Patients using tamsulosin for <1 month had an average OD-OS difference of 0.85±0.5 mm. Patients who were on tamsulosin for >1 month had an average OD-OS difference of 0.52±0.32 mm (P<0.01, Mann-Whitney). CONCLUSION: Patients treated with tamsulosin demonstrated a significantly decreased iris dilatory response to the selective adrenergic effects of phenylephrine compared to controls. Additionally, it appears that longer duration of exposure to tamsulosin increases the likelihood of dilator dysfunction.