AI in Neuro-Ophthalmology: Current Practice and Future Opportunities.

BACKGROUND: Neuro-ophthalmology frequently requires a complex and multi-faceted clinical assessment supported by sophisticated imaging techniques in order to assess disease status. The current approach to diagnosis requires substantial expertise and time. The emergence of AI has brought forth innovative solutions to streamline and enhance this diagnostic process, which is especially valuable given the shortage of neuro-ophthalmologists. Machine learning algorithms, in particular, have demonstrated significant potential in interpreting imaging data, identifying subtle patterns, and aiding clinicians in making more accurate and timely diagnosis while also supplementing nonspecialist evaluations of neuro-ophthalmic disease. EVIDENCE ACQUISITION: Electronic searches of published literature were conducted using PubMed and Google Scholar. A comprehensive search of the following terms was conducted within the Journal of Neuro-Ophthalmology: AI, artificial intelligence, machine learning, deep learning, natural language processing, computer vision, large language models, and generative AI. RESULTS: This review aims to provide a comprehensive overview of the evolving landscape of AI applications in neuro-ophthalmology. It will delve into the diverse applications of AI, optical coherence tomography (OCT), and fundus photography to the development of predictive models for disease progression. Additionally, the review will explore the integration of generative AI into neuro-ophthalmic education and clinical practice. CONCLUSIONS: We review the current state of AI in neuro-ophthalmology and its potentially transformative impact. The inclusion of AI in neuro-ophthalmic practice and research not only holds promise for improving diagnostic accuracy but also opens avenues for novel therapeutic interventions. We emphasize its potential to improve access to scarce subspecialty resources while examining the current challenges associated with the integration of AI into clinical practice and research.

Retinal disease in the neurology clinic.

PURPOSE OF REVIEW: Retinal disease can manifest with visual symptoms similar to those which result from central nervous system disorders. We provide a framework for considering retinal causes of common visual complaints presenting to a neurology clinic. RECENT FINDINGS: Technological advances have afforded quicker detection and a more thorough understanding of these retinal entities and are crucial to consider when evaluating visual complaints in the neurology clinic. SUMMARY: It is essential to maintain a working knowledge of common retinal conditions that symptomatically overlap with common neurologic conditions. Furthermore, the ophthalmoscopic exam and retinal imaging modalities can both aid in the diagnosis and workup of visual complaints and neurologic disease.

Updates on ophthalmic imaging features of optic disc drusen, papilledema, and optic disc edema.

PURPOSE OF REVIEW: Optic nerve head elevation can be associated with vision loss. This review provides an update regarding key features of optic disc drusen (ODD) compared with papilledema from increased intracranial pressure and optic disc edema from other causes. RECENT FINDINGS: Clinical history and funduscopic examination are not sufficient to correctly diagnose different causes of optic nerve head elevation. Multimodal ophthalmic imaging is noninvasive and should be used as first-line diagnostic testing to distinguish optic disc edema or papilledema from pseudoedema. Advanced ophthalmic imaging, including enhanced depth imaging optical coherence tomography (EDI-OCT) and autofluorescence imaging, can visualize ODD at high resolution and determine whether there is optic disc edema. OCT angiography does not require contrast and can rapidly visualize papillary, peripapillary, and macular microvasculature and identify important vascular biomarker of ischemia and, potentially, visual prognosis. SUMMARY: Multimodal ophthalmic imaging can help in the diagnosis of ODD and optic disc edema and identify patients at high risk of vision loss and neurological issues in order to ensure appropriate diagnosis and treatment.

Advances in ophthalmic structural and functional measures in multiple sclerosis: do the potential ocular biomarkers meet the unmet needs?

PURPOSE OF REVIEW: Multiple sclerosis is a heterogeneous disorder. Biomarkers to monitor disease activities are highly desirable especially because of the recent shift toward personalized medicine that coincides with the expansion of disease-modifying therapy. The visual system is highly involved in multiple sclerosis, and the rapid advancement of ophthalmic techniques has boosted the development of potential ocular biomarkers for multiple sclerosis management. RECENT FINDINGS: Recent studies have found that the rapid thinning of the peripapillary retinal nerve fiber layer and ganglion cell-inner plexiform layer (GCIPL) occurs in the progressive stage. Furthermore, the inter-eye thickness difference of the GCIPL could be used in identifying unilateral optic neuritis to facilitate the early diagnosis of multiple sclerosis. Moreover, the retinal microvascular alterations measured as vessel density were found to be related to the disability and visual function, although a standardized protocol to measure retinal microvascular alterations has not been well established. Additionally, aberrant ocular motility, such as fixation microsaccades, can be used to measure disability objectively. SUMMARY: The fast expansion of potential ocular biomarkers measured as retinal microstructural, microvascular, and ocular motility changes may facilitate the diagnosis and management of multiple sclerosis.

Optic neuropathy and diplopia from thyroid eye disease: update on pathophysiology and treatment.

PURPOSE OF REVIEW: Thyroid eye disease (TED) is a disfiguring disease that can lead to neuro-ophthalmic manifestations including diplopia and optic neuropathy. The aim of this review is to shed light on the diagnosis of TED based on clinical examination findings and diagnostic imaging. We will also discuss gold standard as well as newly emerging therapies for TED. RECENT FINDINGS: We discussed diagnostic criteria for TED and differentiating TED from other causes of binocular diplopia. We also reviewed the pathophysiology and differential diagnoses for dysthyroid optic neuropathy as well as recent developments on controversial causes. New imaging techniques are available for evaluation and prognosis of TED comorbidities. Most of the recent developments in TED have been focused on new treatment modalities that have thus far had promising results. We reviewed recently approved and novel potential therapies that are helpful in treating both diplopia and dysthyroid optic neuropathy. SUMMARY: TED is a complicated disorder with many clinical manifestations as well as treatment modalities. Our aim of this review was to outline new developments in the diagnosis and management of TED.

Cataract grading systems: a review of past and present.

PURPOSE OF REVIEW: To provide a comprehensive summary of past cataract grading systems, how they have shaped current grading systems, and the developing technologies that are being used to assess and grade cataracts. RECENT FINDINGS: This summary of cataract grading systems examines the development and limitations that existed in past grading systems and how they have shaped the grading systems of present time. The Lens Opacities Classification System III (LOCS III) system is currently used both clinically and for research purposes. Recent advancements in imaging technologies have allowed researchers to create automatic systems that can locate lens landmarks and provide cataract grading scores that correlate well with LOCS III clinical grades. Utilizing existing technologies, researchers demonstrate that fundus photography and optical coherence tomography can be used as cataract grading tools. Lastly, deep learning has proved to be a powerful tool that can provide objective and reproducible cataract grading scores. SUMMARY: Cataract grading schemes have provided ophthalmologists with a way to communicate clinical findings and to compare new developments in diagnostic technologies. As technologies advance, cataract grading can become more objective and standardized, allowing for improved patient care.

Routine colonoscopy, diabetic eye care, mammogram and pap smear screening in vascular surgery patients.

Objective An increasing emphasis on preventive medicine has been supported by the recent reforms in United States health care system. Majority of the patients seen in vascular surgery clinics are elderly with more extensive medical comorbidities compared to the general population. Thus, these patients would be expected at higher risk for common malignant pathologies such as colon, breast and cervical cancer, and nonmalignant diseases such as diabetic retinopathy. This study looked at the screening compliance of vascular patients compared to data provided by Centers for Disease Control on the national and state levels. Methods The office records of 851 consecutive patients seen in Brooklyn and Staten Island vascular clinics were examined. We queried patients regarding their last colonoscopy, diabetic eye exams, recent mammograms, and Pap smears. Our patient screening compliance was compared between the two clinics as well as to the national and New York state data provided by Centers for Disease Control. Compliance with regard to patient's age was also examined. Results Patients referred to the Staten Island office have a better colonoscopy compliance compared to the Brooklyn office ( P = .0001) and the national Centers for Disease Control average ( P = .026). Compliance for mammography and cervical cancer screening was higher in Staten Island office compared to the Brooklyn office ( P = .0001, P < .0001), respectively. Compliance was lower for Pap smear ( P = .0273) in Brooklyn when compared to the national average. Compliance for colonoscopy increased with age for both clinics ( P = .001, P < .001), while Pap smear decreased ( P < .001, P = .004). Conclusion Patients in vascular clinics in an urban setting had better adherence to screening protocol than the national and state average, with the exception of female patients for colonoscopy in our Brooklyn vascular office. There exists variability in both patient populations based on sub-specific locality and demographics including socioeconomic status. Overall, however patients in Staten Island had better compliance and adherence to the screening protocol than Brooklyn vascular clinic.

Orbital exenteration: Institutional review of evolving trends in indications and rehabilitation techniques.

PURPOSE: To determine the changes in indications for orbital exenteration over 20 years and to assess its impact on patient survival. Evolving techniques of rehabilitation of the orbit in our institution were also evaluated. METHODS: This was a retrospective review of hospital records of patients who underwent orbital exenteration from 1995 to 2015 in a tertiary care center. Data extracted included primary location of the tumor, preoperative treatments, interval between initial diagnosis and exenteration, status of surgical margins, presence of metastatic disease, and postoperative survival. The types of prosthesis utilized over the years were also reviewed. Cox regression analysis was performed for categorical variables. Kaplan-Meier analysis was used to estimate post-exenteration survival. RESULTS: Over a 20-year period, orbital exenteration was performed on 100 orbits of 100 patients. The mean age was 39.4 years (range: 2 months to 90 years). The most common indications among 98 malignant causes were retinoblastoma, squamous cell carcinoma, basal cell carcinoma, extraocular extension of uveal melanoma, and conjunctival melanoma. Postoperative survival was significantly related to age and tumor location but independent from gender, surgical margin, histopathological diagnosis, previous treatment modality, and preoperative interval. In the whole cohort, 1-year and 5-year survival rates were 97% and 84%, respectively. CONCLUSIONS: Exenteration appears to be life-saving in children with orbital extension of retinoblastoma. While patients exenterated for malignant eyelid tumors have the best chance of survival, those with orbital extension of uveal melanoma and adenoid cystic carcinoma of the lacrimal gland have the worst prognosis.

The Future of Imaging in Detecting Glaucoma Progression.

Ocular imaging has been heavily incorporated into glaucoma management and provides important information that aids in the detection of disease progression. Longitudinal studies have shown that the circumpapillary retinal nerve fiber layer is an important parameter for glaucoma progression detection, whereas other studies have demonstrated that macular parameters, such as the ganglion cell inner plexiform layer and optic nerve head parameters, also are useful for progression detection. The introduction of novel technologies with faster scan speeds, wider scanning fields, higher resolution, and improved tissue penetration has enabled the precise quantification of additional key ocular structures, such as the individual retinal layers, optic nerve head, choroid, and lamina cribrosa. Furthermore, extracting functional information from scans such as blood flow rate and oxygen consumption provides new perspectives on the disease and its progression. These novel methods promise improved detection of glaucoma progression and better insight into the mechanisms of progression that will lead to better targeted treatment options to prevent visual damage and blindness.

Recent Developments in the Diagnosis and Treatment of Ocular Toxoplasmosis.

Ocular toxoplasmosis, a chorioretinal infection with Toxoplasma gondii, is the most common etiology of posterior uveitis in many countries. Accurate diagnosis depends heavily on the characteristic clinical features of this disease, but atypical presentations, especially in immunocompromised patients, may create diagnostic challenges and lead to misdiagnosis and inappropriate treatment. Molecular biology techniques to diagnose ocular toxoplasmosis have been available for many years and are now accessible as standard laboratory tests in many countries. Aqueous humor or vitreous evaluation to detect parasite DNA by polymerase chain reaction or specific antibody may provide definitive evidence for rapid diagnosis. Oral pyrimethamine and sulfadiazine plus systemic corticosteroids are an effective therapy for ocular toxoplasmosis. Recent data supports the use of other treatment approaches, including intravitreal antibiotics. The aim of the present review is to discuss briefly the new diagnostic tools and treatment options for ocular toxoplasmosis.

Plus Disease in Retinopathy of Prematurity: Improving Diagnosis by Ranking Disease Severity and Using Quantitative Image Analysis.

PURPOSE: To determine expert agreement on relative retinopathy of prematurity (ROP) disease severity and whether computer-based image analysis can model relative disease severity, and to propose consideration of a more continuous severity score for ROP. DESIGN: We developed 2 databases of clinical images of varying disease severity (100 images and 34 images) as part of the Imaging and Informatics in ROP (i-ROP) cohort study and recruited expert physician, nonexpert physician, and nonphysician graders to classify and perform pairwise comparisons on both databases. PARTICIPANTS: Six participating expert ROP clinician-scientists, each with a minimum of 10 years of clinical ROP experience and 5 ROP publications, and 5 image graders (3 physicians and 2 nonphysician graders) who analyzed images that were obtained during routine ROP screening in neonatal intensive care units. METHODS: Images in both databases were ranked by average disease classification (classification ranking), by pairwise comparison using the Elo rating method (comparison ranking), and by correlation with the i-ROP computer-based image analysis system. MAIN OUTCOME MEASURES: Interexpert agreement (weighted κ statistic) compared with the correlation coefficient (CC) between experts on pairwise comparisons and correlation between expert rankings and computer-based image analysis modeling. RESULTS: There was variable interexpert agreement on diagnostic classification of disease (plus, preplus, or normal) among the 6 experts (mean weighted κ, 0.27; range, 0.06-0.63), but good correlation between experts on comparison ranking of disease severity (mean CC, 0.84; range, 0.74-0.93) on the set of 34 images. Comparison ranking provided a severity ranking that was in good agreement with ranking obtained by classification ranking (CC, 0.92). Comparison ranking on the larger dataset by both expert and nonexpert graders demonstrated good correlation (mean CC, 0.97; range, 0.95-0.98). The i-ROP system was able to model this continuous severity with good correlation (CC, 0.86). CONCLUSIONS: Experts diagnose plus disease on a continuum, with poor absolute agreement on classification but good relative agreement on disease severity. These results suggest that the use of pairwise rankings and a continuous severity score, such as that provided by the i-ROP system, may improve agreement on disease severity in the future.

ULTRA-WIDEFIELD FUNDUS IMAGING: A Review of Clinical Applications and Future Trends.

PURPOSE: To review the basic principles of ultra-widefield fundus imaging and discuss its clinical utility for a variety of retinal and choroidal disorders. METHODS: A systematic review of the PubMed database was performed using the search terms Optos, optomap, panoramic, ultra-widefield, wide-angle, and ellipsoid mirror. This yielded 158 publications of which 128 were selected based on content and relevance. RESULTS: A total of 128 articles pertaining to ultra-widefield imaging were cited in this review. CONCLUSION: Optos ultra-widefield imaging has become an essential tool for the identification of peripheral retinal and vascular pathology. The high resolution and multimodal capabilities of this device are also providing new insights into a variety of disorders, even those that primarily involve the posterior pole. Although the presence of artifact and the need for clinical validation are significant hurdles to more widespread use, ultra-widefield is evolving to become the standard-of-care imaging modality for many diseases and is finding new clinical and research applications such as for screening and telemedicine.

Retinal Imaging: Past, Present, and Future.

Summary The field of retinal imaging has grown in leaps and bounds over the past 10 years. As these new technologies allow us to visualize different pathologies and anatomy, it is critical that we take the time to establish a consensus on what is normal, in order to define what is abnormal. We might consider how this technology affects the diagnosis and treatment of eye disorders and diseases, and ultimately, most importantly, the patient.

[Modern approach to early diagnosis and pathogenetic treatment of diabetic retinopathy]. / Sovremennye podkhody k rannei diagnostike, patogeneticheskomu lecheniyu diabeticheskoi retinopatii.

AIM: To improve the approach to pathogenetic treatment of diabetic retinopathy (DR) through early diagnosis and a new method for predicting disease progression. MATERIAL AND METHODS: The study enrolled 330 type 2 diabetes patients with DR (660 eyes), of whom women constituted 64.6%, men - 35.4%. The mean patient age was 62.3±2.3 years. Three groups were formed: the controls - 30 healthy volunteers (60 eyes) and 30 type 2 diabetes patients without ocular involvement (DR 0, 60 eyes); group 1 - 30 type 2 diabetes patients with DR I but no diabetic macular edema (DR I without DME, 60 eyes) that were treated with calcium dobesilate; group 2 - 240 type 2 diabetes patients, who had diabetic retinopathy of different stages (DR I, II, or III with DME, 480 eyes) and received laser retinal photocoagulation (LRP). The groups were all alike in terms of sex and age distribution. All patients underwent ophthalmic examination, including best corrected visual acuity (BCVA) and critical flicker fusion frequency (CFFF) testing, tonometry, biomicroscopy, MAIA fundus microperimetry, optical coherence tomography (OCT), and fluorescein angiography (FAG) of the retina. Traditionally we also determined blood sugar and glycated hemoglobin levels as well as vascular endothelial growth factor (VEGF-A) and monocyte chemoattractant protein (MCP-1) in tear fluid by ELISA. RESULTS: In group 1, which was under conservative therapy with calcium dobesilate, there was an increase in BCVA by the average of 0.95±0.02 and CFFF by 42.5±0.2 Hz (p<0,05). The mean central retinal thickness decreased reliably down to 265.1±12.1 µm (p<0.05). Light sensitivity of the macula improved and scored 24.13±12.3 dB (p<0.05). In group 2, the mean central retinal thickness appeared to be 383.1±221 µm, which was reliably higher than that in healthy individuals (p<0.05) and in type 2 diabetes patients without diabetic retinopathy (DR 0) (p<0.05). Tear assessment 12 months after the treatment revealed a significant decrease in VEGF-A and MCP-1 concentrations - down to 655.1±86.1 pg/ml and 1133 pg/ml, respectively (p<0.05). CONCLUSION: Conservative treatment with calcium dobesilate has proved effective in patients with DR I without DME as it ensures improvement and stabilization of the state of the retina (clinical and morphological) in one month already (judging from FAG and OCT findings). Laser treatment is rational in DR I, DR II, and DR III patients, whose condition is complicated with DME. Improvement and stabilization take, however, longer to be achieved - up to 1 year (according to FAG and OCT). Tear fluid assessment for particular participants in disease pathogenesis, such as VEGF-A and MCP-1, is a unique method for disease control and patient follow-up with account to different treatments. A new method for predicting the progression of diabetic retinopathy and diabetic macular edema has been suggested (RF patent for invention №2520826).

[Fundamental ophthalmology: the role of electrophysiological studies].

Studying of functional aspects of eye disease pathogenesis by electrophysiological methods is widely demanded in fundamental ophthalmology. Introduction of modern methods of functional assessment into experimental and clinical projects significantly broadens knowledge of normal and pathological functioning of the visual system and is the basis for further development of new strategies of pathogenetic treatment, diagnostics and expert evaluation. Some problems of ophthalmology, including those that concern age-related macular degeneration, glaucoma, diabetic retinopathy, and other diseases, are considered in the context of how much electrophysiology contributes to their solution. The role of functional examinations of the retina in studying pathophysiology of neurodegenerative brain diseases, such as Alzheimer's and Parkinson's, is also discussed.

[Keratoconus: modern approaches to pathogenetic studies, diagnosis, optical correction, and treatment].

OBJECTIVE: To evaluate modern approaches to pathogenetic studies, diagnosis, optical correction, and treatment of keratoconus (KC). MATERIAL AND METHODS: Research results over the recent years obtained with up-to-date methods of pathogenetic studying, diagnosis, correction, and treatment of KC are presented. RESULTS: Modern approaches to KC consist in analysis of corneal composition and trace elements migration as well as influencing factors. Topographic keratometry and pachymetry proved effective in early detection of KC. Results of intrastromal corneal segments implantation and corneal collagen cross-linking for optical correction and prevention of progression of KC are presented. The use of contact lenses and penetrative keratoplasty for optical correction in KC is comparatively analyzed. A new technique of complete corneal stromoplasty with viscoablation, which does not require anterior corneal stroma pre-separation and removal over the whole area of transplantation and ensures good visual control of Descemet's membrane separation, is suggested. Combined eximer laser photorefractive and phototherapeutic keratectomy for early keratoconus is theoretically substantiated. CONCLUSION: In most patients the discussed methods ensure prevention of progression of keratoconus, optical correction, and treatment. Prospects of further improvement of early diagnosis and treatment are associated with profound studying of the disease pathogenesis.

[State-of-the-art cataract surgery and intraocular optical correction].

The paper provides current knowledge on cataract epidemiology worldwide and in the Russian Federation, including issues of cataractogenesis and prevention. An overview of medical equipment for preoperative and intraoperative diagnostics is provided. Key aspects of the conventional ultrasonic phacoemulsification method as well as the most marked trends in correction of aphakia with intraocular lenses and in design of the latter are presented. Major laser-assisted techniques, including those that imply the use of femtosecond laser systems, and results that they yielded to date are discussed in detail.

Diagnostic techniques for inflammatory eye disease: past, present and future: a review.

Investigations used to aid diagnosis and prognosticate outcomes in ocular inflammatory disorders are based on techniques that have evolved over the last two centuries have dramatically evolved with the advances in molecular biological and imaging technology. Our improved understanding of basic biological processes of infective drives of innate immunity bridging the engagement of adaptive immunity have formed techniques to tailor and develop assays, and deliver targeted treatment options. Diagnostic techniques are paramount to distinguish infective from non-infective intraocular inflammatory disease, particularly in atypical cases. The advances have enabled our ability to multiplex assay small amount of specimen quantities of intraocular samples including aqueous, vitreous or small tissue samples. Nevertheless to achieve diagnosis, techniques often require a range of assays from traditional hypersensitivity reactions and microbe specific immunoglobulin analysis to modern molecular techniques and cytokine analysis. Such approaches capitalise on the advantages of each technique, thereby improving the sensitivity and specificity of diagnoses. This review article highlights the development of laboratory diagnostic techniques for intraocular inflammatory disorders now readily available to assist in accurate identification of infective agents and appropriation of appropriate therapies as well as formulating patient stratification alongside clinical diagnoses into disease groups for clinical trials.