Use of an Artificial Intelligence-Generated Vascular Severity Score Improved Plus Disease Diagnosis in Retinopathy of Prematurity.

PURPOSE: To evaluate whether providing clinicians with an artificial intelligence (AI)-based vascular severity score (VSS) improves consistency in the diagnosis of plus disease in retinopathy of prematurity (ROP). DESIGN: Multireader diagnostic accuracy imaging study. PARTICIPANTS: Eleven ROP experts, 9 of whom had been in practice for 10 years or more. METHODS: RetCam (Natus Medical Incorporated) fundus images were obtained from premature infants during routine ROP screening as part of the Imaging and Informatics in ROP study between January 2012 and July 2020. From all available examinations, a subset of 150 eye examinations from 110 infants were selected for grading. An AI-based VSS was assigned to each set of images using the i-ROP DL system (Siloam Vision). The clinicians were asked to diagnose plus disease for each examination and to assign an estimated VSS (range, 1-9) at baseline, and then again 1 month later with AI-based VSS assistance. A reference standard diagnosis (RSD) was assigned to each eye examination from the Imaging and Informatics in ROP study based on 3 masked expert labels and the ophthalmoscopic diagnosis. MAIN OUTCOME MEASURES: Mean linearly weighted κ value for plus disease diagnosis compared with RSD. Area under the receiver operating characteristic curve (AUC) and area under the precision-recall curve (AUPR) for labels 1 through 9 compared with RSD for plus disease. RESULTS: Expert agreement improved significantly, from substantial (κ value, 0.69 [0.59, 0.75]) to near perfect (κ value, 0.81 [0.71, 0.86]), when AI-based VSS was integrated. Additionally, a significant improvement in plus disease discrimination was achieved as measured by mean AUC (from 0.94 [95% confidence interval (CI), 0.92-0.96] to 0.98 [95% CI, 0.96-0.99]; difference, 0.04 [95% CI, 0.01-0.06]) and AUPR (from 0.86 [95% CI, 0.81-0.90] to 0.95 [95% CI, 0.91-0.97]; difference, 0.09 [95% CI, 0.03-0.14]). CONCLUSIONS: Providing ROP clinicians with an AI-based measurement of vascular severity in ROP was associated with both improved plus disease diagnosis and improved continuous severity labeling as compared with an RSD for plus disease. If implemented in practice, AI-based VSS could reduce interobserver variability and could standardize treatment for infants with ROP. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Non-mydriatic ultra-widefield diffraction-limited retinal imaging.

We demonstrate a new non-mydriatic ultra-widefield optical coherence tomography retinal imaging system, designed with custom optics to improve the imaging field of view, lateral resolution, and patient comfort. The key motivation is to address the challenge with conventional systems that require pupillary dilation, adding time, expense, discomfort, and medical risk to the examination of the retina. Our system provides an ultrawide 100° field of view (beam scanning angle at the scanning pivot point) and maintains a lateral resolution of 20 µm on the center. It also allows a generous working distance of 16 mm, 2-3 times longer than existing ultra-widefield OCT imaging systems. This advanced system was able to avoid iris vignetting artifacts without pharmacological dilation and ensure diffraction-limited ultra-widefield imaging under a generalized eye model. This enables a comprehensive evaluation of retina diseases, especially those affecting the peripheral regions.

Implementation of optical coherence tomography in retinopathy of prematurity screening.

PURPOSE OF REVIEW: In this review, we explore the investigational applications of optical coherence tomography (OCT) in retinopathy of prematurity (ROP), the insights they have delivered thus far, and key milestones for its integration into the standard of care. RECENT FINDINGS: While OCT has been widely integrated into clinical management of common retinal diseases, its use in pediatric contexts has been undermined by limitations in ergonomics, image acquisition time, and field of view. Recently, investigational handheld OCT devices have been reported with advancements including ultra-widefield view, noncontact use, and high-speed image capture permitting real-time en face visualization. These developments are compelling for OCT as a more objective alternative with reduced neonatal stress compared to indirect ophthalmoscopy and/or fundus photography as a means of classifying and monitoring ROP. SUMMARY: OCT may become a viable modality in management of ROP. Ongoing innovation surrounding handheld devices should aim to optimize patient comfort and image resolution in the retinal periphery. Future clinical investigations may seek to objectively characterize features of peripheral stage and explore novel biomarkers of disease activity.

Search engine optimization and its association with readability and accessibility of diabetic retinopathy websites.

PURPOSE: This study investigated whether websites regarding diabetic retinopathy are readable for patients, and adequately designed to be found by search engines. METHODS: The term "diabetic retinopathy" was queried in the Google search engine. Patient-oriented websites from the first 10 pages were categorized by search result page number and website organization type. Metrics of search engine optimization (SEO) and readability were then calculated. RESULTS: Among the 71 sites meeting inclusion criteria, informational and organizational sites were best optimized for search engines, and informational sites were the most visited. Better optimization as measured by authority score was correlated with lower Flesch Kincaid Grade Level (r = 0.267, P = 0.024). There was a significant increase in Flesch Kincaid Grade Level with successive search result pages (r = 0.275, P = 0.020). Only 2 sites met the 6th grade reading level AMA recommendation by Flesch Kincaid Grade Level; the average reading level was 10.5. There was no significant difference in readability between website categories. CONCLUSION: While the readability of diabetic retinopathy patient information was poor, better readability was correlated to better SEO metrics. While we cannot assess causality, we recommend websites improve their readability, which may increase uptake of their resources.

The influence of the topographic location of geographic atrophy on vision-related quality of life in nonexudative age-related macular degeneration.

PURPOSE: To examine associations between the topographic distribution of geographic atrophy (GA) and vision-related quality of life (VRQoL). METHODS: This study included 237 eyes from 161 participants in the Age-Related Eye Disease Study (AREDS). GA lesions were manually delineated with color fundus photographs obtained by the AREDS Research Group and atrophic area was measured in an Early Treatment Diabetic Retinopathy Study (ETDRS) grid. VRQoL was measured using the National Eye Institute Visual Function Questionnaire (NEI-VFQ). Area of atrophy in the ETDRS grid subfields was correlated with VRQoL by linear regression modeling. RESULTS: The average area of atrophy in the better and worse eye was 3.43mm2 and 7.15mm2 respectively. In multivariable analysis, VRQoL was not associated with total area of atrophy in the better eye (ß, - 0.53; 95% confidence interval [CI], - 1.11 to 0.05; P = 0.07) or worse eye (ß, 0.12; 95% CI, - 0.32 to 0.55; P = 0.59). However, area of atrophy in the central 1-mm-diameter zone of the better eye was significantly associated with VRQoL when the ETDRS subfields were examined individually (ß, - 14.57; 95% CI, - 27.12 to - 2.02; P = 0.023), grouped into quadrants (ß, - 18.35; 95% CI, - 30.03 to - 6.67; P = 0.002), inner and outer zones (ß, - 17.26; 95% CI, - 29.38 to - 5.14; P = 0.006), or vertical and horizontal zones (ß, - 18.97; 95% CI, - 30.18 to - 7.77; P = 0.001). CONCLUSION: In patients with GA, greater area of atrophy in the central 1-mm-diameter zone of the better eye was independently associated with lower VRQoL, while total area of atrophy in the better or worse eye was not.

Commercially Available Prenatal Vitamins Do Not Meet American College of Obstetricians and Gynecologists Nutritional Guidelines.

OBJECTIVE: This study aimed to evaluate the reported amount of the American College of Obstetricians and Gynecologists (ACOG) recommended nutrients in commercially available, over-the-counter prenatal vitamins (PNVs) in the United States, to assess their adequacy compared with the ACOG guidelines, and to compare these supplements by cost. STUDY DESIGN: The top 30 online Amazon and Google shopping items found using "prenatal vitamins" in September 2022 were included for analysis if they included the words "prenatal" and "vitamin" in the label and contained multiple nutrients. Duplicates between Amazon and Google were excluded as well as vitamins that did not list all ingredients. The reported amounts of 11 key nutrients, as recommended by the ACOG, for each product were recorded, as well as supplemental form and cost per 30-day supply. A cost analysis was done of PNVs that met the ACOG recommendations for the highlighted nutrients compared with those that did not. Five out of the 11 key nutrients (folic acid, iron, docosahexaenoic acid, vitamin D, and calcium) were specifically highlighted, as deficiencies in these nutrients are known to correlate with significant clinical outcomes in pregnancy. RESULTS: A total of 48 unique PNVs were included for final analysis. Of these PNVs, none were compliant with suggested amounts of all five key vitamins and nutrients. No products met daily recommendations for calcium. Only five PNVs were compliant with recommendations with ⅘ key nutrients. Of note, 27% of PNVs did not have the recommended amount of folic acid (13/48). The median cost of PNVs that were not compliant with the four nutrients mentioned above was $18.99 (interquartile range [IQR]: $10.00-$30.29), which was not statistically different from the median cost of the PNVs that did meet compliance with the four nutrients, which was $18.16 (IQR: $9.13-$26.99), p = 0.55. CONCLUSION: There were significant variations in the level of nutrients and cost of commercially available, over-the-counter PNVs in the United States. This raises concern that there should be more regulation of PNVs. KEY POINTS: · Commercially available over the counter PNVs vary in their content of the ACOG recommended nutrients and vitamins for pregnancy.. · None of these studied PNVs contain adequate amounts of all five key nutrients.. · Cost is not correlated with more compliance with the ACOG recommendations..

Geographic atrophy severity and mortality in age-related macular degeneration.

PURPOSE: To examine the association between geographic atrophy (GA) disease characteristics and mortality risk. METHODS: We manually delineated color fundus photographs of 209 Age-Related Eye Disease Study (AREDS) participants with GA secondary to age-related macular degeneration to identify total area of atrophy, GA effective radius growth rate, disease laterality, and the presence of foveal center involvement. Associations between GA characteristics and mortality were assessed with Cox proportional hazards models adjusted for health status indicators. RESULTS: During a median follow-up of 6.8 years, 48 (23.0%) participants with GA died. In adjusted models, accounting for age, sex, and health status, participants with total GA area in the highest quartile had a significantly increased risk of all-cause mortality compared to those with total GA area in the lowest quartile (hazard ratio [HR], 3.42; 95% confidence interval [CI], 1.32-8.86; P = 0.011). GA effective radius growth rate, bilateral disease, and the presence of foveal center involvement were not significantly associated with mortality. In a multivariable model, including health status indicators and all GA characteristics, total area of atrophy in the highest quartile remained significantly associated with mortality (HR, 4.65; 95% CI, 1.29-16.70; P = 0.019). CONCLUSIONS: More extensive GA, as indicated by a greater total area of atrophy, was associated with an increased risk of all-cause mortality in our cohort. The extent of GA may reflect the extent of underlying disease processes that contribute to greater mortality risk, further suggesting that GA may be part of a systemic rather than purely ocular disease process.

2020 Evaluation of Portable Vision Screening Instruments.

Amblyopia is the most common cause of preventable visual impairment in children and occurs as a result of unilateral or bilateral impairment in best-corrected visual acuity. Early diagnosis and proper treatment are crucial to prevent poor visual outcomes in adulthood. Advances in technology have provided more objective diagnostic tools, which can now be used by a wide range of healthcare providers. Here, we highlight tools that have gained popularity in the past two decades and compare clinically relevant parameters to guide primary care providers seeking to incorporate instrumental vision screening in pediatric patient care.

Assessment of presurgical psychological screening in patients undergoing spine surgery: use and clinical impact.

STUDY DESIGN: Prospective survey. OBJECTIVE: To determine the prevalence of use of presurgical psychological screening (PPS) among spine surgeons in the United States, identify factors associated with PPS use, evaluate surgeons' opinions of PPS, and investigate how PPS is applied in clinical practice. SUMMARY OF BACKGROUND DATA: The United States Preventive Services Task Force recommends PPS for patients undergoing back surgery. The prevalence of PPS is unknown. Thus, it may be difficult to improve preoperative care for such patients with psychological conditions. METHODS: An online survey invitation was emailed to 340 spine surgeons. Questions addressed surgeon characteristics (eg, number of years in practice), practice characteristics (eg, practice type), inclusion of integrated rehabilitation and psychological services, and use of PPS. The impact of psychological factors on rehabilitation and recovery was assessed using an 11-point Likert scale (0, no impact; 10, highest impact). We analyzed the 110 (32%) responses with a χ(2) test (significance, P<0.05). RESULTS: PPS was used by 37% (41) to screen for depression (100%) or anxiety (85%). PPS use was highest among surgeons with more experience, higher annual volume, and no university affiliation. Among those screening for fear avoidance, use was highest among surgeons more recently entering the field. Surgeons reported a strong belief regarding the impact of psychological factors on pain relief, adherence to therapy, and return to work (mean impact rating, >7.0); however, impact on return for follow-up was only moderate (mean rating, 5.8). CONCLUSIONS: A minority of surgeons reported using PPS. Surgeons were less likely to use PPS if they had completed residency or begun practice within 14 years, had fewer than 200 cases annually, or were university affiliated. This study highlights the need to advocate for the use of North American Spine Society guidelines regarding the use of PPS.

Chorioretinal Anastomosis and Retinal Detachment with Laser Photocoagulation Treated Incontinentia Pigmenti.

PURPOSE: To describe a case of incontinentia pigmenti in which chorioretinal anastomosis occurred after laser photocoagulation, which was ultimately complicated by tractional and rhegmatogenous detachment. METHODS: Observational case report. RESULTS: A 2-month-old was referred to ophthalmology for a rash characteristic of incontinentia pigmenti due to concern for ocular involvement and was found to have peripheral avascular retina with early neovascularization. Following several rounds of panretinal photocoagulation, a chorioretinal anastomosis was noted on follow up fluorescein angiography in the left eye. Subsequently, a tractional retinal detachment formed and was treated initially with a lens sparing pars plana vitrectomy, endolaser, and scleral buckle. Despite treatment, it progressed to a combined tractional/rhegmatogenous detachment and was deemed inoperable. CONCLUSION: Chorioretinal anastomosis is a rare complication of laser photocoagulation.

Classification and Growth Rate of Chorioretinal Atrophy after Voretigene Neparvovec-Rzyl for RPE65-Mediated Retinal Degeneration.

PURPOSE: Classify the appearance and quantify the growth rate of chorioretinal atrophy in patients who received voretigene neparvovec-rzyl (VN) for RPE65-mediated retinal degeneration. DESIGN: Multicenter retrospective analysis. SUBJECTS: Patients who underwent subretinal VN injection at 5 institutions and demonstrated posterior-pole chorioretinal atrophy. METHODS: Ultrawidefield scanning laser ophthalmoscopy or color fundus photos were assessed before and after subretinal VN. Atrophy was defined as regions with ≥ 2 of the following: (1) partial or complete retinal pigment epithelial depigmentation; (2) round shape; (3) sharp margins; and (4) increased visibility of choroidal vessels. Atrophy was qualitatively classified into different subtypes. All atrophy was manually segmented. Linear mixed-effects models with random slopes and intercepts were fit using atrophy area and square root of atrophy area. MAIN OUTCOME MEASURES: Number of eyes with each atrophy pattern, and slopes of linear mixed-effects models. RESULTS: Twenty-seven eyes from 14 patients across 5 centers developed chorioretinal atrophy after subretinal VN. A mean of 5.8 ± 2.7 images per eye obtained over 2.2 ± 0.8 years were reviewed, and atrophy was categorized into touchdown (14 eyes), nummular (15 eyes), and perifoveal (12 eyes) subtypes. Fifteen eyes demonstrated > 1 type of atrophy. Thirteen of 14 patients demonstrated bilateral atrophy. The slopes of the mixed-effects models of atrophy area and square root of atrophy area (estimate ± standard error) were 1.7 ± 1.3 mm2/year and 0.6 ± 0.2 mm/year for touchdown atrophy, 5.5 ± 1.3 mm2/year and 1.2 ± 0.2 mm/year for nummular atrophy, and 16.7 ± 1.8 mm2/year and 2.3 ± 0.2 mm/year for perifoveal atrophy. The slopes for each type of atrophy were significantly different in the square root of atrophy model, which best fit the data (P < 0.05). CONCLUSIONS: Chorioretinal atrophy after subretinal VN for RPE65-mediated retinal degeneration developed according to a touchdown, nummular, and/or perifoveal pattern. Perifoveal atrophy grew the most rapidly, while touchdown atrophy grew the least rapidly. Understanding the causes of these findings, which are present in a minority of patients, merits further investigation. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Isolated Retinal Neovascularization in Retinopathy of Prematurity: Clinical Associations and Prognostic Implications.

OBJECTIVE: Isolated retinal neovascularization (IRNV) is a common finding in patients with stage 2 and 3 retinopathy of prematurity (ROP). This study aimed to further classify the clinical course and significance of these lesions (previously described as "popcorn" based on clinical appearance) in patients with ROP as visualized with ultrawidefield OCT (UWF-OCT). DESIGN: Single center, retrospective case series. PARTICIPANTS: Images were collected from 136 babies in the Oregon Health and Science University neonatal intensive care unit. METHODS: A prototype UWF-OCT device captured en face scans (>140°), which were reviewed for the presence of IRNV along with standard zone, stage, and plus classification. In a cross-sectional analysis we compared demographics and the clinical course of eyes with and without IRNV. Longitudinally, we compared ROP severity using a clinician-assigned vascular severity score (VSS) and compared the risk of progression among eyes with and without IRNV using multivariable logistic regression. MAIN OUTCOME MEASURES: Differences in clinical demographics and disease progression between patients with and without IRNV. RESULTS: Of the 136 patients, 60 developed stage 2 or worse ROP during their disease course, 22 of whom had IRNV visualized on UWF-OCT (37%). On average, patients with IRNV had lower birth weights (BWs) (660.1 vs. 916.8 g, P = 0.001), gestational age (GA) (24.9 vs. 26.1 weeks, P = 0.01), and were more likely to present with ROP in zone I (63.4% vs. 15.8%, P < 0.001). They were also more likely to progress to stage 3 (68.2% vs. 13.2%, P < 0.001) and receive treatment (54.5% vs. 15.8%, P = 0.002). Eyes with IRNV had a higher peak VSS (5.61 vs. 3.73, P < 0.001) and averaged a higher VSS throughout their disease course. On multivariable logistic regression, IRNV was independently associated with progression to stage 3 (P = 0.02) and requiring treatment (P = 0.03), controlling for GA, BW, and initial zone 1 disease. CONCLUSIONS: In this single center study, we found that IRNV occurs in higher risk babies and was an independent risk factor for ROP progression and treatment. These findings may have implications for OCT-based ROP classifications in the future. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Panretinal handheld OCT angiography for pediatric retinal imaging.

Comprehensive visualization of retina morphology is essential in the diagnosis and management of retinal diseases in pediatric populations. Conventional imaging techniques often face challenges in effectively capturing the peripheral retina, primarily due to the limitations in current optical designs, which lack the necessary field of view to characterize the far periphery. To address this gap, our study introduces a novel ultra-widefield optical coherence tomography angiography (OCTA) system. This system, specifically tailored for pediatric applications, incorporates an ultrahigh-speed 800 kHz swept-source laser. The system's innovative design achieves a 140° field of view while maintaining excellent optical performance. Over the last 15 months, we have conducted 379 eye examinations on 96 babies using this system. It demonstrates marked efficacy in the diagnosis of retinopathy of prematurity, providing detailed and comprehensive peripheral retinal angiography. The capabilities of the ultra-widefield handheld OCTA system in enhancing the clarity and thoroughness of retina vascularization assessments have significantly improved the precision of diagnoses and the customization of treatment strategies. Our findings underscore the system's potential to advance pediatric ophthalmology and broaden the scope of retinal imaging.

Multinational External Validation of Autonomous Retinopathy of Prematurity Screening.

Importance: Retinopathy of prematurity (ROP) is a leading cause of blindness in children, with significant disparities in outcomes between high-income and low-income countries, due in part to insufficient access to ROP screening. Objective: To evaluate how well autonomous artificial intelligence (AI)-based ROP screening can detect more-than-mild ROP (mtmROP) and type 1 ROP. Design, Setting, and Participants: This diagnostic study evaluated the performance of an AI algorithm, trained and calibrated using 2530 examinations from 843 infants in the Imaging and Informatics in Retinopathy of Prematurity (i-ROP) study, on 2 external datasets (6245 examinations from 1545 infants in the Stanford University Network for Diagnosis of ROP [SUNDROP] and 5635 examinations from 2699 infants in the Aravind Eye Care Systems [AECS] telemedicine programs). Data were taken from 11 and 48 neonatal care units in the US and India, respectively. Data were collected from January 2012 to July 2021, and data were analyzed from July to December 2023. Exposures: An imaging processing pipeline was created using deep learning to autonomously identify mtmROP and type 1 ROP in eye examinations performed via telemedicine. Main Outcomes and Measures: The area under the receiver operating characteristics curve (AUROC) as well as sensitivity and specificity for detection of mtmROP and type 1 ROP at the eye examination and patient levels. Results: The prevalence of mtmROP and type 1 ROP were 5.9% (91 of 1545) and 1.2% (18 of 1545), respectively, in the SUNDROP dataset and 6.2% (168 of 2699) and 2.5% (68 of 2699) in the AECS dataset. Examination-level AUROCs for mtmROP and type 1 ROP were 0.896 and 0.985, respectively, in the SUNDROP dataset and 0.920 and 0.982 in the AECS dataset. At the cross-sectional examination level, mtmROP detection had high sensitivity (SUNDROP: mtmROP, 83.5%; 95% CI, 76.6-87.7; type 1 ROP, 82.2%; 95% CI, 81.2-83.1; AECS: mtmROP, 80.8%; 95% CI, 76.2-84.9; type 1 ROP, 87.8%; 95% CI, 86.8-88.7). At the patient level, all infants who developed type 1 ROP screened positive (SUNDROP: 100%; 95% CI, 81.4-100; AECS: 100%; 95% CI, 94.7-100) prior to diagnosis. Conclusions and Relevance: Where and when ROP telemedicine programs can be implemented, autonomous ROP screening may be an effective force multiplier for secondary prevention of ROP.

Eyes for Ears: Usage and Efficacy of a Podcast for Ophthalmic Education.

Purpose: To characterize listenership and perceived educational impact of the ophthalmic podcast "Eyes for Ears". Methods: A cross-sectional, internet-distributed, 9-question Qualtrics survey was made available to podcast listeners. Listenership metrics were analyzed from the podcast host platform. Results: From January 10, 2019 to September 2, 2021, the podcast was downloaded over 422,000 times, averaging about 4442 downloads per episode. 209 Qualtrics survey responses were analyzed from podcast listeners with backgrounds in eye care including medical students, residents, fellows, clinicians and technicians. The majority were residents (60.3%), representative of the target audience of the podcast. Listeners reported using the podcast while commuting (81.3%), felt it increased the time they could spend on self-care (63.2%), and thought it improved their fund of knowledge (99.0%). Respondents recalled feeling better prepared for the OKAP or written boards after using this podcast (before median = 50/100 on Likert Scale, IQR 30-65 vs median = 70/100, IQR 56-81, p <0.001). Respondents identified question banks as the most helpful for OKAP studying, followed by podcasts. Podcasts were preferred over articles and lectures in terms of helpfulness (p < 0.001). Conclusion: The Eyes for Ears podcast has achieved a robust international audience. The surveyed audience felt the podcast was useful for their education and well-being.

Patient Perceptions of Retinal Detachment Management and Recovery through Social Media.

PURPOSE: Social media support groups can provide accessibility to advice and emotional regarding medical topics, such as retinal detachment repair, but this is almost universally provided by laypersons. We sought to determine how topics related to retinal detachment repair are associated with various emotional responses and the spread of misinformation, as identified through an online social media support group. METHODS: Retrospective observational study of the largest Facebook support group for retinal detachment from 03/19/2021 to 07/19/2021. Members of the support group that posted during the study period. Comments were coded by content (Pre-procedural, Peri-procedural Post procedural, Repeat procedures) and participant response (Emotional responses, Asking for medical advice, and Misinformation). Associations between content and responses were examined using Pearson's chi-squared test, two-sample t-test, and linear regression. RESULTS: Posts that included written comments from the study period were analyzed. Negative emotional responses appeared in 30% of posts and positive emotional responses were in 16% of posts. Misinformation was more likely to appear in pre-procedure posts (5.3% versus 1.4%, p = .03). Negative emotional responses trended towards being more common in topics related to repeat procedures (40% vs 28%), although this did not reach statistical significance (p = .06). CONCLUSIONS: Surgeons should be aware that patients frequently express negative experiences on this forum, asked for medical advice, even in the post-operative period, and that these posts generated high engagement. Misinformation may be propagated in support groups, though less commonly with regard to post-procedural questions.