THE ABILITY OF ARTIFICIAL INTELLIGENCE CHATBOTS ChatGPT AND GOOGLE BARD TO ACCURATELY CONVEY PREOPERATIVE INFORMATION FOR PATIENTS UNDERGOING OPHTHALMIC SURGERIES.

INTRODUCTION: To determine whether the two popular artificial intelligence chatbots, ChatGPT and Bard, can provide high-quality information concerning procedure description, risks, benefits, and alternatives of various ophthalmic surgeries. METHODS: ChatGPT and Bard were prompted with questions pertaining to the description, potential risks, benefits, alternatives, and implications of not proceeding with various surgeries in different subspecialties of ophthalmology. Six common ophthalmic procedures were included in the authors' analysis. Two comprehensive ophthalmologists and one subspecialist graded each response independently using a 5-point Likert scale. RESULTS: Likert grading for accuracy was significantly higher for ChatGPT in comparison with Bard (4.5 ± 0.6 vs. 3.8 ± 0.8, P < 0.0001). Generally, ChatGPT performed better than Bard even when questions were stratified by the type of ophthalmic surgery. There was no significant difference between ChatGPT and Bard for response length (2,104.7 ± 271.4 characters vs. 2,441.0 ± 633.9 characters, P = 0.12). ChatGPT responded significantly slower than Bard (46.0 ± 3.0 vs. 6.6 ± 1.2 seconds, P < 0.0001). CONCLUSION: Both ChatGPT and Bard may offer accessible and high-quality information relevant to the informed consent process for various ophthalmic procedures. Nonetheless, both artificial intelligence chatbots overlooked the probability of adverse events, hence limiting their potential and introducing patients to information that may be difficult to interpret.

Evaluating patient flow through an emergency ophthalmology consult service in a tertiary care academic centre in Quebec.

OBJECTIVE: This study aims to characterize the epidemiology, common reasons, and diagnostic accuracy of referrals made by emergency departments (EDs) and optometrists to an emergency ophthalmology consultation service as well as to identify opportunities for improvement. DESIGN: Retrospective chart review. PARTICIPANTS: A total of 1249 referrals made to the emergency ophthalmology consultation service at a tertiary care centre between July 2018 and June 2019. METHODS: Patient charts were examined, and clinical variables were extracted. Statistical significance (p < 0.05) was determined via t tests and χ2 tests for continuous and categorical variables, respectively. Diagnostic accuracy of providers and time delay between referral and ophthalmologic encounter also were assessed. RESULTS: Both EDs and optometrists most often referred cases with vitreoretinal (36.48% and 37.19%, respectively) and corneal pathology (21.42% and 20.25%, respectively). Optometrists (n = 240; 52.48%) were significantly more accurate in their diagnoses than EDs (n = 940; 32.45%; p < 0.00001). Specifically, optometrists were significantly more accurate when diagnosing anterior-chamber (n = 29; 58.62%; p = 0.039) and vitreoretinal (n = 89; 60.67%; p < 0.00001) pathology than EDs (anterior chamber, n = 77, 36.36%; vitreoretinal, n = 344, 18.90%). Across all ED referrals (n = 940), 58 (6.17%) had a prolonged delay. Across all optometrist-to-ED referrals (n = 150), 6 (4.00%) had a prolonged delay. Accounting for all cases, the total incidence of prolonged delay was 5.87%. CONCLUSIONS: Our results demonstrate the need for improved communication between optometrists and ophthalmologists to reduce the wait-time burden on EDs. Patients may benefit from direct referral by optometrists to ophthalmologists. Education of allied health professionals on ophthalmic disease also may improve diagnostic accuracy.

EXTENSIVE ORBITAL AND PARAPHARYNGEAL EMPHYSEMA REQUIRING URGENT CANTHOTOMY AND CANTHOLYSIS AFTER PARS PLANA VITRECTOMY.

PURPOSE: The authors report the emergent management of a case of orbital and parapharyngeal emphysema causing orbital compartment syndrome and signs of peripheral neuropathy days after pars plana vitrectomy. METHODS: Case report. RESULTS: A 20-year-old woman underwent 3-port 23-gauge pars plana vitrectomy in the right eye for total retinal detachment under general anesthesia. All sclerotomies were secured with 7-0 polyglactin 910 (Vicryl; Ethicon) sutures before instillation of 15% C3F8 gas. On the third postoperative day, the patient presented with a 3-mm proptosis, near-total ophthalmoplegia, jaw protrusion, head deviation, tongue protrusion, and facial twitching. Computed tomography showed extensive subcutaneous gas in the right orbit and bilateral parapharyngeal spaces, and a tethered right optic nerve with globe tenting. A decision was made to perform urgent lateral canthotomy and cantholysis. Three hours after canthotomy and cantholysis, her neurologic signs had resolved except for intermittent tongue protrusion, which resolved thereafter. At postoperative Week 7, the patient's vision was 20/70 and her intraocular pressure was 13 mmHg. CONCLUSION: To the authors' knowledge, this is the only report of a modern small-gauge vitrectomy procedure being complicated by orbital compartment syndrome and extensive emphysema causing peripheral neuropathy, and successfully treated with urgent canthotomy and cantholysis.

The Isabel Differential Diagnosis Generator for Orbital Diagnosis.

PURPOSE: The Isabel differential diagnosis generator is one of the most widely known electronic diagnosis decision support tools. The authors prospectively evaluated the utility of Isabel for orbital disease differential diagnosis. METHODS: The terms "proptosis," "lid retraction," "orbit inflammation," "orbit tumour," "orbit tumor, infiltrative" and "orbital tumor, well-circumscribed" were separately input into Isabel and the results were tabulated. Then the clinical details (patient age, gender, signs, symptoms, and imaging findings) of 25 orbital cases from a textbook of orbital surgery were entered into Isabel. The top 10 differential diagnoses generated by Isabel were compared with the correct diagnosis. RESULTS: Isabel identified hyperthyroidism and Graves ophthalmopathy as the leading causes of lid retraction, but many common causes of proptosis and orbital tumors were not correctly elucidated. Of the textbook cases, Isabel correctly identified 4/25 (16%) of orbital cases as one of its top 10 differential diagnoses, and the median rank of the correct diagnosis was 6/10. Thirty-two percent of the output diagnoses were unlikely to cause orbital disease. CONCLUSION: Isabel is currently of limited value in the mainstream orbital differential diagnosis. The incorporation of anatomic localizations and imaging findings may help increase the accuracy of orbital diagnosis.

Incidence of ophthalmologic pathology and associated risk factors in orbital fractures at a level I trauma centre.

OBJECTIVE: To estimate the incidence of ophthalmologic pathology at presentation of patients with orbital fracture to a level I trauma centre and the most significant associated risk factors. METHODS: A total of 244 patients with 278 fractured orbits over a 2-year period at a level I trauma centre were reviewed. The primary outcome was the incidence of urgent ophthalmologic pathology, defined as requiring attention without delay. Patient demographics, history, findings on radiographic imaging, and physical examination findings at initial and follow-up examinations were recorded. Odds ratios with 95% confidence intervals were calculated. RESULTS: On initial examination and follow-up, 9.7% of orbits had ophthalmologic pathology. Only 3 patients (1.1%) had urgent pathology, including orbital compartment syndrome and globe rupture, whereas 22 patients (7.9%) had semiurgent pathology and 4 patients (1.4%) had nonurgent pathology. Subjective decreased vision (odds ratio [OR] = 3.5; p = 0.021), assault-related injuries (OR = 2.4; p = 0.036), work-related injuries (OR = 7.7; p = 0.004), afferent pupillary defect (OR = 19.2; p = 0.017), anisocoria (OR = 7.8; p = 0.001), and symmetrical extraocular movement limitation (OR = 5.2; p = 0.003) and fixed pupil (OR = 16.9; p < 0.001) had statistically significant odds ratios associated with pathology. Patient sex, eye involved, intoxication, anticoagulation, and antiplatelets, as well as previous ocular surgery, were not associated with pathology. CONCLUSIONS: Most orbital fractures do not present with ophthalmologic pathology. Subjective vision loss, history of assault or work trauma, and pupil abnormalities on examination were the greatest risk factors for pathology. Our results highlight the most important factors on patient presentation that should prompt first responders to seek urgent ophthalmologic consultation.

Clinical and anatomic correlates of objectively measured zonular dehiscence in 427 postmortem pseudophakic eyes.

OBJECTIVE: This study aims to objectively measure the degree of zonular dehiscence in postmortem eyes and to assess for clinical and anatomic correlates. DESIGN: Cross-sectional study. MATERIALS: Four hundred and twenty-seven postmortem pseudophakic human eyes. METHODS: Eyes were obtained from the Lions Gift of Sight Eye Bank. Microscope photographs were taken of the eyes in Miyake-Apple view, and region-of-interest analysis was performed using ImageJ to measure the area, circumference, and diameter of the capsular bag, the ciliary ring, and the capsulorhexis. Clinical and anatomic parameters were assessed using simple linear regression analysis and one-way analysis of variance with post hoc Bonferroni testing. Zonular dehiscence was measured via 2 surrogates: capsule area over ciliary ring area ratio (CCR) and capsule-ciliary ring decentration (CCD). Low CCR and high CCD indicate more zonular dehiscence. RESULTS: CCR was significantly inversely correlated with smaller capsulorhexi (p = 0.012), lower intraocular lens power (p < 0.00001), younger age at death (p = 0.00002), and a longer cataract-to-death time (p = 0.00786). CCR also was significantly lower in glaucomatous cases (p = 0.0291). CCD was significantly correlated with longer cataract-to-death time (p = 0.000864), larger ciliary ring area (p = 0.001), more posterior capsule opacification (p = 0.0234), and higher Soemmering's ring opacity (p = 0.0003). There was also significantly more decentration in male eyes than in female eyes (p = 0.00852). CONCLUSIONS: CCR and CCD are novel measures of zonular dehiscence in postmortem eyes, with many interesting correlates. An enlarged ciliary ring area is possibly associated with zonular dehiscence in pseudophakic eyes and may be a quantifiable surrogate in vivo.

Significance of subconjunctival hemorrhage in predicting ocular pathology for patients with orbital fracture.

OBJECTIVE: Subconjunctival hemorrhage (SCH) is a common presentation in patients with orbital trauma and often warrants investigation of underlying ocular pathology. Our study aims to assess the significance of SCH severity, graded in a spatial 0-360° manner, as a predictor for ocular pathology in patients with orbital fracture. DESIGN: Retrospective chart review. PARTICIPANTS: Patients with fractured orbits (n = 265) presenting to a level 1 trauma centre between August 2015 and January 2018. METHODS: Key elements of ophthalmic assessment, including visual acuity, SCH (0-360°), anterior- and posterior-segment examination, Hertel exophthalmometry, and ocular pathology, were recorded. Simple logistic regression assessed for association between SCH severity and ocular pathology. Odds ratios (ORs) were calculated with 95% CI. RESULTS: Among the 265 fractured orbits, 158 (59.6%) presented with no SCH, and 107 (40.4%) had some degree of SCH. Ocular pathology was noted in 24 fractured orbits (9%). Most common pathologies included entrapment (22.2%), hyphema (16.7%), traumatic optic neuropathy (8.3%), and commotio retinae (8.3%). Simple logistic regression revealed a higher incidence of ocular pathology with increasing severity of SCH from 0-360° (OR = 1.004; 95% CI 1.001-1.007; p = 0.0085). In addition, χ2 analysis demonstrated a higher proportion of ocular pathology in 181-270° (25.0%; p = 0.0466) and 271-360° SCH subgroups (26.3%; p = 0.0031) compared with the 0° SCH subgroup (6.3%). CONCLUSIONS: Our findings suggest that there is some correlation between the extent of SCH and ocular pathology. However, patient care and investigations should continue to be directed by a full clinical assessment of patients with orbital trauma.

A technique for excisional optic nerve biopsy.

PURPOSE: To describe a transconjunctival technique for full-thickness (excisional) optic nerve biopsy. METHOD: A medial transconjunctival approach to the optic nerve with disinsertion of the medial rectus is used. A small right-angle Mixter forcep is used to clamp the optic nerve far posteriorly, and then a microscalpel is directed metal-on-metal to cut the posterior optic nerve. The cut nerve is then rotated anteriorly to complete the proximal nerve cut. RESULT: A full-thickness specimen of 11 mm of more can be obtained without undue traction on the globe. The globe remains viable. CONCLUSION: A long length, excisional optic nerve biopsy can be readily and safely performed without endoscopic techniques.

Clinical correlations of extraocular motility limitation pattern in orbital fracture cases: a retrospective cohort study in a level 1 trauma centre.

PURPOSE: Ocular pathology (OP) following orbital fracture can vary vastly in complexity and severity. Extra-ocular motility (EOM) limitations are frequently present in orbital trauma cases, with patterns of duction limitations being symmetrical or asymmetrical. The aim of this study was to identify if there was any association between increased OP following orbital fracture cases based on the pattern of EOM deficits. METHODS: This is a retrospective cohort study of patients with fractured orbits presenting with or without EOM limitations to a level 1 trauma center between August 2015 to January 2018. All pertinent elements of the ophthalmic examination were recorded. Outcome measures: Chi-square analyses assessed for association between symmetrical or asymmetrical EOM limitation and OP. Odds ratios were calculated with 95% confidence interval. RESULTS: 278 orbits with wall fractures were included in this study. A significant correlation between EOM limitation and increased OP following orbital trauma was found (p = 0.000081). Cases with symmetrical and asymmetrical EOM limitation were 7.9 (95%CI: 2.3-27.2) and 5.22 (95%CI: 1.9-13.9) times more likely to have OP than cases with no EOM limitation, respectively. With extraocular muscle entrapment excluded, cases with symmetrical limitations had a significantly higher incidence of OP than cases with asymmetrical limitations (p = 0.0161). CONCLUSIONS: OP is frequently observed in cases of orbital fracture. While any EOM limitations should prompt the clinicians to anticipate OP, intra-ocular injury may be more likely in cases of symmetrical EOM limitation. Future prospective studies are needed to further elucidate the relationship between EOM symmetricity and OP following orbital trauma.

Primary care assessment of orbital trauma at a level 1 trauma centre.

OBJECTIVE: With increasing constraints on our publicly funded health care system, appropriate triage of trauma patients is becoming pivotal, making the primary care assessment (PCA) invaluable. Our study aims to compare the initial assessment of patients with orbital fractures with that conducted by the ophthalmology service. DESIGN: Retrospective chart review. PARTICIPANTS: 243 patients with 277 fractured orbits presenting to a level 1 trauma centre seen between August 2015 and January 2018. METHODS: Key elements of the PCA, including subjective vision loss, visual acuity, intraocular pressure, pupil examination, and extraocular movements, were documented and compared with the assessment by the ophthalmology service as the control. The primary outcome was inter-rater reliability as estimated by Cohen's kappa (κ) coefficient. Secondary outcomes included the sensitivity and specificity, as well as the rate of completion of examination components. RESULTS: PCA examination findings agreed with the ophthalmology service on most components of the examination with the highest agreement with relative afferent pupillary defects and detection of hyphemas (κ = 1). Primary care physicians less often performed most aspects of the assessment. Among performed components of the examination, the average sensitivity was 60.6%, and the average specificity was 84.2%. CONCLUSIONS: Our results show good inter-rater reliability of the PCA compared with the ophthalmology examination but low rate of completion of examination components, suggesting a potential overdependence on the ophthalmology assessment. Given the limited resources of the public health care system, our study may highlight the PCA as a potential focus to improve effective and safe patient management.

Unilateral upper eyelid eversion and kink associated with epidemic keratoconjunctivitis.

PURPOSE: Upper lid eversion in adults from non-cicatricial causes is rare. We report a case of upper eyelid eversion secondary to epidemic keratoconjunctivitis (EKC). OBSERVATIONS: A 37 year-old female presented with unilateral upper lid eversion. Known for left upper lid ptosis repair in childhood, the patient presented with seven-day history of severe bilateral conjunctivitis and eversion of her left upper lid three days prior. On exam, she had follicular conjunctivitis, punctate epithelial keratopathy with subepithelial infiltrates and membranes bilaterally, with an everted upper lid tarsus, and swollen and ulcerated palpebral conjunctiva. She received topical and oral prednisone to quickly reduce the inflammation, as well as moxifloxacin drops and lubrication. When the swelling subsided, the tarsus adopted a kinked and everted configuration, and was managed successfully with reversion, pressure patching, shielding and close follow-up. CONCLUSIONS AND IMPORTAMCE: This is the first reported case of upper lid eversion secondary to EKC, likely due to sudden marked inflammation and edema of the posterior lamella caused by the adenoviral infection. This case was successfully managed with conservative therapy.

Quality of life considerations in uveal melanoma patients: a systematic review.

OBJECTIVE: The aim of this study is to examine the quality of life (QOL) outcomes of patients undergoing different uveal melanoma (UM) treatments and to appraise the literature on the topic. DESIGN AND PARTICIPANTS: A systematic review was conducted to address the study objective. Patients undergoing UM treatment with or without metastasis were eligible for inclusion in this review. METHODS: A literature search was performed using National Library of Medicine (PubMed), Embase, Ovid online, and Cochrane Central Register of Controlled Trials databases. We included all English, original retrospective or prospective studies published between January 1998 to September 2019 in which the primary outcome was the QOL of patients with treated UM. RESULTS: Our search strategy yielded 101 articles. Of these, 18 articles met all our inclusion criteria. The majority of included articles (61%) are cross-sectional studies. On average, each study employed 2 different QOL assessment tools. Overall, physical functioning and mental well-being are impaired in patients with UM after treatment compared with the general population. The severity of the impairment decreases as early as 3 months post-treatment; 8 of 12 studies comparing treatment options reported no statistical difference in physical functioning between treatments; 4 of 12 studies reported better visual function with radiation therapy compared with enucleation, 2 of which described no difference between the 2 options at long-term. Anxiety is more prevalent than depression, and both decrease to less than 10% at 1-year follow-up. CONCLUSIONS: Overall, there is no significant difference in long-term QOL in patients with UM from different treatment groups past 1-year follow-up. This work underscores the need for and importance of developing a standardized, complete assessment tool tailored to the challenges inherent to the diagnosis of UM.

Incidence and outcomes of retrobulbar hematoma diagnosed by computed tomography in cases of orbital fracture.

OBJECTIVE: Retrobulbar hemorrhage (RBH) is a potentially sight-threatening complication of orbital fractures causing an orbital compartment syndrome (OCS). RBH causing OCS is regarded as a clinical diagnosis when evidence of optic nerve compression is found. Nonetheless, many patients with facial trauma will have received imaging by computed tomography (CT) on which there is documented RBH, with or without signs of OCS. The aim of this study was to identify the incidence and describe the outcomes of these CT-diagnosed RBH. METHODS: This is a retrospective chart review of patients with orbital fractures for which ophthalmology was consulted. Confirmation of orbital fracture and presence of an RBH on facial-bones CT was recorded. Patient demographics, proptosis, visual acuity, intraocular pressure and interventions received at initial visit and follow-up were recorded. RESULTS: 292 orbits with wall fractures were identified. 94 (32.2%) were documented by CT to have RBH. Of these orbits, only one (1.1%) was diagnosed with OCS receiving canthotomy and cantholysis. 53 orbits with initial CT-diagnosed retrobulbar hematoma were seen in follow-up a week or more later, none of which had developed signs of OCS or needed medical or surgical intervention for OCS. CONCLUSIONS: RBH is a frequently reported finding on CT in cases of orbital fractures. In this study, almost all of these CT-diagnosed RBH did not develop OCS initially or by the time of follow-up. CT presence of RBH is not an accurate predictor for OCS, and the diagnosis and treatment of OCS should be directed clinically.

Posterior vitreous detachment and incidence of delayed retinal breaks: a retrospective, 2-year study at an academic centre.

OBJECTIVE: Posterior vitreous detachment (PVD) is common in older patients, particularly postcataract surgery. Patients are typically followed 4 to 6 weeks after the initial presentation. The study goal was to assess the rate of new retinal tears for patients without new symptoms on routine follow-up. METHODS: This is a multisite, retrospective cohort study of all patients presenting to the emergency departments at an academic health centre in a 2-year period diagnosed with uncomplicated PVD. Patient demographics, pastocular surgery, retinal findings at the first and second examinations, and the identity of the examiner were recorded. The primary outcome was absence of new retinal tears or pathology on follow-up. RESULTS: One hundred sixty-six patients were identified, and 105 patients were present for both an initial and follow-up examination (median, 6 weeks). No patients had any new pathology on the follow-up examination. Most patients (n = 62) were seen initially by one of 15 residents alone, and most patients (n = 80) were seen at follow-up by one of 10 staff from specialties of comprehensive, uveitis, neuro-ophthalmology, cornea, and retina. The remaining 25 patients were seen in follow-up by residents. CONCLUSION: To our knowledge, this is the first study on the incidence of delayed retinal breaks with the examination performed by a variety of residents and comprehensive and subspecialist staff. Our results suggest there may be limited benefit to routine follow-up of PVD patients without new symptoms, including when followed by nonretina ophthalmologists. These findings could allow for better health care resources management.

Cavernous sinus syndrome associated with metastatic colorectal cancer and perineural spread along the trigeminal nerve.

PURPOSE: We report the case of a patient with cavernous sinus syndrome associated with biopsy-confirmed metastasis from colorectal cancer. OBSERVATIONS: A patient known for laryngeal carcinoma and metastatic colorectal carcinoma presented with symptoms of left trigeminal neuralgia and progressive, near-complete ophthalmoplegia. Magnetic resonance imaging (MRI) revealed a mass in the left cavernous sinus, extending into Meckel's cave with perineural spread along the mandibular branch of the left trigeminal nerve. A transsphenoidal biopsy was performed and demonstrated metastatic colon adenocarcinoma. We review the existing literature on colorectal cancer associated cavernous sinus syndrome. CONCLUSIONS AND IMPORTANCE: Cavernous sinus metastasis from colorectal cancer is exceedingly rare. We report the second case of this entity with histopathologic confirmation, and the first case with concurrent perineural spread involving the trigeminal nerve. Cavernous sinus metastasis may represent a poor prognostic factor in colorectal cancer.

Radiology Exposure in the Undergraduate Curriculum: A Medical Student Perspective on Quality and Opportunities for Positive Change.

PURPOSE: This article is a continuation of a qualitative study designed to explore how radiology exposures can impact medical student opinions and perceptions of radiology and radiologists. We focused on: 1) conducting a radiology exposure inventory from the perspective of the medical student; 2) student evaluation of the quality of the radiology exposures and suggestions for positive change; and 3) development of a framework to address the needs of medical students as it relates to radiology education in the undergraduate medical curriculum. METHODS: Research methodology and design for this qualitative study were described in detail in a previous article by Visscher et al [1]. RESULTS: Participants included 28 medical students; 18 were in medical school years 1 and 2 (preclerkship), and 10 were in years 3 and 4 (clerkship). Specific to the focus of this article, the data revealed 3 major findings: 1) multiple exposures to radiology exist, and they are received and valued differently depending on the medical student's stage of professional development; 2) medical students value radiology education and want their radiology exposure to be comprehensive and high quality; 3) Medical students have constructive suggestions for improving the quality of both formal and informal radiology exposures. CONCLUSIONS: Performing a radiology exposure inventory from a medical student perspective is a useful way to explore how students receive and value radiology instruction. Medical students want a more comprehensive radiology education that can be summarized using the 5 C's of Radiology Education framework. The 5 C's (curriculum, coaching, collaborating, career and commitment) reflect medical students' desires to learn content that will support them in clinical practice, be supported in their professional development, and have the necessary information to make informed career decisions.

The Exposure Dilemma: Qualitative Study of Medical Student Opinions and Perceptions of Radiology.

PURPOSE: According to a national survey of over 900 Canadian medical students, the stereotype of an isolated radiologist working in a dark room persists. The purpose of this study is to use qualitative methods to explore the ways exposure to radiology in medical school impacts students' opinions and perceptions of radiology and radiologists. METHODS: After receiving ethics approval, 4 focus groups were conducted, 1 per year of undergraduate medical training at Western University. The transcribed audio recordings and accompanying field notes, together with the open-ended questions obtained from the national survey, were analyzed using thematic analysis. RESULTS: Five hundred sixty students in medical school years 1 and 2 (preclerkship) participated in the national survey and 18 in the focus groups; 336 students in years 3 and 4 [clerkship] participated in the national survey and 10 in the focus groups. Three major findings emerged from the analysis of the data. First, stereotypes are perpetuated mainly through informal interactions. Second, there is limited exposure to radiology and radiologists in medical school, especially in preclerkship. Third, students want to know what to expect if they choose a career in radiology. CONCLUSIONS: Medical students, especially those in preclerkship, are seeking accurate information to modify or reinforce radiology stereotypes. Limited exposure makes interactions with students impactful and mentorship essential. Students want meaningful interactions with radiologists and radiology residents.