Triaging ophthalmology outpatient referrals with machine learning: A pilot study.

IMPORTANCE: Triaging of outpatient referrals to ophthalmology services is required for the maintenance of patient care and appropriate resource allocation. Machine learning (ML), in particular natural language processing, may be able to assist with the triaging process. BACKGROUND: To determine whether ML can accurately predict triage category based on ophthalmology outpatient referrals. DESIGN: Retrospective cohort study. PARTICIPANTS: The data of 208 participants was included in the project. METHODS: The synopses of consecutive ophthalmology outpatient referrals at a tertiary hospital were extracted along with their triage categorizations. Following pre-processing, ML models were applied to determine how accurately they could predict the likely triage categorization allocated. Data was split into training and testing sets (75%/25% split). ML models were tested on an unseen test set, after development on the training dataset. MAIN OUTCOME MEASURE: Area under the receiver operator curve (AUC) for category one vs non-category one classification. RESULTS: For the main outcome measure, convolutional neural network (CNN) provided the best AUC (0.83) and accuracy on the test set (0.81), with the artificial neural network (AUC 0.81 and accuracy 0.77) being the next best performing model. When the CNN was applied to the classification task of identifying which referrals should be allocated a category one vs category two vs category three priority, a lower accuracy was achieved (0.65). CONCLUSIONS AND RELEVANCE: ML may be able to accurately assist with the triaging of ophthalmology referrals. Future studies with data from multiple centres and larger sample sizes may be beneficial.

Medical Devices; Ophthalmic Devices; Classification of the Intranasal Electrostimulation Device for Dry Eye Symptoms. Final order.

The Food and Drug Administration (FDA or we) is classifying the intranasal electrostimulation device for dry eye symptoms into class II (special controls). The special controls that apply to the device type are identified in this order and will be part of the codified language for the intranasal electrostimulation device for dry eye symptoms' classification. We are taking this action because we have determined that classifying the device into class II (special controls) will provide a reasonable assurance of safety and effectiveness of the device. We believe this action will also enhance patients' access to beneficial innovative devices, in part by reducing regulatory burdens.

Medical Devices; Ophthalmic Devices; Classification of the Tear Electrostimulation Device. Final order.

The Food and Drug Administration (FDA or we) is classifying the tear electrostimulation device into class II (special controls). The special controls that apply to the device type are identified in this order and will be part of the codified language for the tear electrostimulation device's classification. We are taking this action because we have determined that classifying the device into class II (special controls) will provide a reasonable assurance of safety and effectiveness of the device. We believe this action will also enhance patients' access to beneficial innovative devices, in part by reducing regulatory burdens.

Medical Devices; Ophthalmic Devices; Classification of Nasolacrimal Compression Device. Final order.

The Food and Drug Administration (FDA) is classifying the nasolacrimal compression device into class I (general controls). The Agency is classifying the device into class I (general controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

Medical Devices; Ophthalmic Devices; Classification of Strabismus Detection Device. Final order.

The Food and Drug Administration (FDA) is classifying the strabismus detection device into class II (special controls). The special controls that will apply to the device are identified in this order and will be part of the codified language for the strabismus detection device's classification. The Agency is classifying the device into class II (special controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

Medical Devices; Ophthalmic Devices; Classification of the Diurnal Pattern Recorder System. Final order.

The Food and Drug Administration (FDA) is classifying the diurnal pattern recorder system into class II (special controls). The special controls that will apply to the device are identified in this order and will be part of the codified language for the diurnal pattern recorder system's classification. The Agency is classifying the device into class II (special controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

Medical Devices; Ophthalmic Devices; Classification of the Oral Electronic Vision Aid. Final order.

The Food and Drug Administration (FDA) is classifying the oral electronic vision aid into class II (special controls). The special controls that will apply to the device are identified in this order and will be part of the codified language for the oral electronic vision aid's classification. The Agency is classifying the device into class II (special controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

Time to declare ophthalmology an independent discipline by initiating Bachelor of Ophthalmic Surgery programme.

Medical education, associated with lengthy, exhaustive pathways requisite of time, energy and efforts, restrain an individual from pursuing a career in medicine. Most students enrol in medical colleges under the influence of their family members, and only some strive to seek medicine as their own ambition. Medical students confront a number of problems in memorising huge amount of data and the various strategies are integrated in MBBS curriculum from time to time. After MBBS programme, most graduates tend to abandon studies, some migrate abroad, a few continue as general physicians and even fewer strive to get registered for postgraduate specialisation. This results in suboptimal supply of medical workforce. Inconsideration of the current ophthalmologist work ratio and growing demand for eye care services, an initiative is put forward to introduce Bachelors of Ophthalmic Surgery programme similar to Bachelor of Dental Surgery. Such initiative may facilitate effective learning, enable command in a particular area and encourage more individuals to pursue a career in ophthalmology. Using a questionnaire to undergraduate medical students, medical professors and ophthalmologists were surveyed to evaluate the efficacy of the proposed initiative. The results threw a mixed response.

Medical devices; ophthalmic devices; classification of the eyelid weight. Final rule.

The Food and Drug Administration (FDA or Agency) is classifying the eyelid weight into class II (special controls). The Agency is exempting the external eyelid weight from premarket notification, but continuing to require premarket notification for implantable eyelid weights in order to provide a reasonable assurance of safety and effectiveness of the device. Both external and implantable eyelid weight devices are subject to special controls. The eyelid weight may be adhered to the outer skin of the upper eyelid (external eyelid weight) or implanted into the upper eyelid (implantable eyelid weight), and is intended for the gravity assisted treatment of lagophthalmos (incomplete eyelid closure).

Medical devices; ophthalmic devices; classification of the scleral plug. Final rule.

The Food and Drug Administration (FDA or Agency) is classifying the scleral plug into class II (special controls), and exempting the scleral plugs composed of surgical grade stainless steel (with or without coating in gold, silver, or titanium) from premarket notification (510(k)) and continuing to require premarket notification (510(k)) for all other scleral plugs in order to provide a reasonable assurance of safety and effectiveness of the device. The scleral plug is a prescription device used to provide temporary closure of a scleral incision during an ophthalmic surgical procedure.

Medical devices; ophthalmic devices; classification of the eyelid thermal pulsation system. Final rule.

The Food and Drug Administration (FDA) is classifying the eyelid thermal pulsation system into class II (special controls). The Agency is classifying the device into class II (special controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

Comparison of the h-indices of the editorial board members of seven ophthalmic subspecialty journals.

PURPOSE: To investigate and compare the h-indices of the editorial board members of ophthalmic subspecialty journals. STUDY DESIGN: Descriptive Cross Sectional Research. METHODS: Bibliometric indices were calculated for the editorial board members of seven ophthalmic subspecialty journals. Correlations between the median h-indexes and journal impact factors (JIF), average citations per article and JIF, and publication count and JIF were analyzed. RESULTS: The median h-indices of the board members of Retina, Journal of Glaucoma, Journal of Cataract and Refractive Surgery, Cornea, Ophthalmic Plastic and Reconstructive Surgery, Journal of Neuroophthalmology and Journal of the American Academy of Pediatric Ophthalmology and Strabismus (J AAPOS) were 34, 26, 23, 17, 15, 14 and 13, respectively. H-indices and publication count were correlated with JIF (P<0.05, for each). CONCLUSION: The board members of Retina have the highest h-index and average citations per article, and J AAPOS have the least. These data provide useful benchmarks for comparison of the various subspecialty areas in ophthalmology.

Testing the reliability of an eye-dedicated triaging system: the RESCUE.

PURPOSE: To calculate the reliability of an eye-dedicated triaging system named Rome Eye Scoring System for Urgency and Emergency (RESCUE). METHODS: There were four coding parameters: pain, redness, loss of vision, and risk of open globe. Each parameter is assigned a score, the sum of which allows color coding. There were 1000 consecutive patients divided into urgent (U) or non-urgent (NU) based upon diagnosis, need for treatment, hospitalization, and/or follow-up visit. Correlation between RESCUE triage scoring as assigned by the nurse on presentation and urgency as estimated retrospectively was calculated. Accuracy, sensitivity, and specificity have been calculated. False positives (FP) have been defined as patients assigned a RESCUE green or yellow code while retrospectively judged NU and false negatives (FN) have been defined as patients assigned a white code despite being considered U. RESULTS: Of 1000 patients, 332 (33.2%) were classified as U and 668 (66.8%) NU. The difference in RESCUE scoring between U and NU patients was significant (p<0.001), as well as the correlation between RESCUE scoring and urgency status. Accuracy was 95% with 9.3% FP and 2.7% FN. Sensitivity was 90.7% and specificity 97.2%. Positive predictive value was 94.6%, and negative predictive value was 95.2%. All 32 hospitalized patients and 147/198 (74.2%) patients given a return appointment properly received a yellow or green code. CONCLUSIONS: RESCUE accuracy, sensitivity, and specificity yield encouraging results, confirming the system''s ability to properly spot the most urgent cases. The concept of urgency in ophthalmology can be difficult to establish; nonetheless, an eye-dedicated triage can help in properly prioritizing urgent patients.

Características clínico-oftalmológicas y evolución de los pacientes con oftalmopatía tiroidea activa moderada severa tratados con bolos de metilprednisolona que acuden al Hospital Central del Instituto de Previsión Social, Paraguay / Clinical-ophthalmological characteristics and evolution of patients with moderately severe active thyroid ophthalmopathy treated with methylprednisolone boluses who attended the Central Hospital of the Instituto de Previsión Social, Paraguay

Introducción: La oftalmopatía tiroidea (OT) es un trastorno debilitante en pacientes con enfermedad tiroidea autoinmune, principalmente enfermedad de Graves, que se desarrolla entre el 30 a 50% de los casos. Objetivos: Describir las características clínico-oftalmológicas y la evolución de los pacientes con oftalmopatía tiroidea activa moderada severa tratados con bolos de metilprednisolona que acuden al Hospital Central del Instituto de Previsión Social en el tiempo comprendido entre enero de 2018 y setiembre de 2021. Materiales y métodos: Investigación de diseño observacional, con estudio descriptivo, retrospectivo. Resultados: Se revisaron fichas de 34 pacientes con OT activa moderada severa que recibieron bolos de metilprednisolona basado en las guías EUGOGO 2016, de los cuáles se excluyeron 3 pacientes por tener fichas incompletas y otros 3 pacientes ya que requirieron tratamiento de segunda línea previo al término del esquema de 12 sesiones. De los 28 pacientes estudiados, la edad promedio fue de 43,6 ±13,1 años, el 89% de sexo femenino y el 28,5%, fumadores. En cuanto a la función tiroidea de la población previo al tratamiento, se constató hipertiroidismo en el 82%, hipotiroidismo en el 11% y eutiroidismo en el 7%; y posterior al tratamiento, se constató hipertiroidismo en el 78,6% (subclínico), eutiroidismo en el 17,9% e hipotiroidismo en el 3,5%. La mayoría (92.6%) contaba con anticuerpos contra el receptor de TSH positivo, con un promedio de 18 ± 9,9 mIU/Ml. Respecto a la actividad de la oftalmopatía según la escala CAS, se constató un promedio de 4,1 ±1,0 previo al tratamiento y posterior 1,2 ±1,4; de ellos el 46,4% presentó un estado leve según escala de gravedad, 39% sin criterios de gravedad y 14 % persistió en moderada -severa. Se constató mejoría de la agudeza visual tras el tratamiento (57,1%), el promedio de exoftalmía previo al tratamiento fue 22,2 mm y posterior 21,1 mm; se presentó diplopía en el 7,1% previo al tratamiento y en el 3,6% posterior al tratamiento. Conclusión: El tratamiento con glucocorticoides endovenosos en la oftalmopatía de Graves moderada-severa (esquema EUGOGO 2016) fue muy efectivo, revirtiendo la actividad y consecuentemente ayudando a disminuir la gravedad, en la gran mayoría de nuestros pacientes. Esto podría explicarse porque la oftalmopatía era incipiente y por el alto grado de adherencia de los pacientes en el contexto de un manejo multidisciplinar bien protocolizado.

Introduction: Graves' orbitopathy (GO) is a debilitating disorder in patients with autoimmune thyroid disease, mainly Graves' disease, which develops in 30 to 50% of cases. Objectives: To describe the clinical-ophthalmological characteristics and evolution of patients with moderate-to- severe active GO treated with methylprednisolone boluses who attended the Central Hospital of the Institute of Social Security between January 2018 and September 2021. Materials and methods: Observational design research, descriptive, retrospective study. Results: Records of 34 patients with active moderate-to-severe GO who received boluses of methylprednisolone based on the EUGOGO 2016 guidelines, were reviewed, of which 3 patients were excluded due to having incomplete records and another 3 patients since they required second-line treatment prior to end the 12-session scheme. Of the 28 patients studied, the average age was 43.6 ±13.1 years, 89% were female and 28.5% were smokers. Regarding the thyroid function of the population prior to treatment, hyperthyroidism was found in 82%, hypothyroidism in 11% and euthyroidism in 7%; and after treatment, hyperthyroidism was found in 78.6% (subclinical), euthyroidism in 17.9% and hypothyroidism in 3.5%. The majority (92.6%) had positive thyrotropin receptor antibodies, with an average of 18 ± 9.9 mIU/Ml. Regarding the activity of orbitopathy according to the CAS scale, an average of 4.1 ±1.0 was found before treatment and 1.2 ±1.4 after; Of them, 46.4% presented a mild condition according to the severity scale, 39% without severity criteria and 14% persisted in moderate-severe. Improvement in visual acuity was noted after treatment (57.1%), the average exophthalmia before treatment was 22.2 mm and after 21.1 mm; Diplopia occurred in 7.1% before treatment and in 3.6% after treatment. Conclusion: Treatment with intravenous glucocorticoids in moderate-severe Graves' orbitopathy (EUGOGO 2016 scheme) was very effective, reversing the activity and consequently helping to reduce the severity, in the vast majority of our patients. This could be explained because the orbitopathy was incipient and by the high degree of patient adherence in the context of well-protocolized multidisciplinary management.

Triaging and coding ophthalmic emergency: the Rome Eye Scoring System for Urgency and Emergency (RESCUE): a pilot study of 1,000 eye-dedicated emergency room patients.

PURPOSE: Ophthalmic emergency (OE) triage is essential for prompt recognition of urgent cases. To date, no formal eye-dedicated triaging system has been widely accepted. The purpose of the present study is to propose a fast, accurate, and reproducible coding scale called the Rome Eye System for Scoring Urgency and Emergency (Rescue). METHODS: Phase 1 of the study is a retrospective analysis of electronic medical records (EMR); phase 2 is a prospective consecutive series. Phase 1 included 160,936 patients. Phase 2 included 1000 consecutive patients referred to the emergency department (ED) of our institution. In phase 1, the authors retrospectively analyzed EMRs of patients presenting to the ED, listing signs and symptoms most frequently associated with hospitalization. Redness, pain, loss of vision, and the risk for an open eye were identified and assigned a score ranging from 0 to 12. Color coding was assigned based on increasing scoring: 0-3 white, 4-7 green, 8-12 yellow code. In phase 2, 1000 consecutive ED patients were enrolled and prospectively coded according to RESCUE. After diagnosis and proper treatment, EMRs were retrospectively reviewed by a masked physician and patients recoded (Retro coding) according to clinical course. Correlation between Rescue and Retro coding was calculated. MAIN OUTCOME MEASURES: Prospective and retrospective ED color coding correlation. RESULTS: A total of 160,936 EMR were retrospectively analyzed; 2407 (1.4%) patients required hospitalization. Loss of vision (90%), redness (76%), and pain (47%) were the most frequent complaints. Rescue significantly correlated to Retro coding (p<0.01): 841/1000 patients coded exactly the same color, 45/1000 were overestimated by one color class, none by two, 107/1000 underestimated by one, and 6/1000 by two classes. The 32/1000 hospitalized patients in the prospective cohort had a Rescue score significantly higher than non-admitted patients (p<0.01) and color coding among admitted and dismissed patients was significantly different as well (p<0.01). CONCLUSIONS: The Rescue system seems promising in terms of usefulness and ease of implementation. The high correlation between Rescue code assigned prospectively and the post-diagnosis coding, as well as the prompt discrimination of cases that eventually required hospitalization, may lead to a wider use of the Rescue system. Further testing on larger samples and different institutions is warranted.

Representation of ophthalmology concepts by electronic systems: adequacy of controlled medical terminologies.

OBJECTIVE: To assess the adequacy of 5 controlled medical terminologies (International Classification of Diseases 9, Clinical Modification [ICD9-CM]; Current Procedural Terminology 4 [CPT-4]; Systematized Nomenclature of Medicine, Clinical Terms [SNOMED-CT]; Logical Identifiers, Names, and Codes [LOINC]; Medical Entities Dictionary [MED]) for representing concepts in ophthalmology. DESIGN: Noncomparative case series. PARTICIPANTS: Twenty complete ophthalmology case presentations were sequentially selected from a publicly available ophthalmology journal. METHODS: Each of the 20 cases was parsed into discrete concepts, and each concept was classified along 2 axes: (1) diagnosis, finding, or procedure and (2) ophthalmic or medical concept. Electronic or paper browsers were used to assign a code for every concept in each of the 5 terminologies. Adequacy of assignment for each concept was scored on a 3-point scale. Findings from all 20 case presentations were combined and compared based on a coverage score, which was the average score for all concepts in that terminology. MAIN OUTCOME MEASURES: Adequacy of assignment for concepts in each terminology, based on a 3-point Likert scale (0, no match; 1, partial match; 2, complete match). RESULTS: Cases were parsed into 1603 concepts. SNOMED-CT had the highest mean overall coverage score (1.625+/-0.667), followed by MED (0.974+/-0.764), LOINC (0.781+/-0.929), ICD9-CM (0.280+/-0.619), and CPT-4 (0.082+/-0.337). SNOMED-CT also had higher coverage scores than any of the other terminologies for concepts in the diagnosis, finding, and procedure categories. Average coverage scores for ophthalmic concepts were lower than those for medical concepts. CONCLUSIONS: Controlled terminologies are required for electronic representation of ophthalmology data. SNOMED-CT had significantly higher content coverage than any other terminology in this study.

[Evaluation of a new residency program at the department of ophthalmology of the Heinrich Heine University Düsseldorf]. / Evaluation eines neuen Weiterbildungsprogramms in der Augenklinik der Heinrich-Heine-Universität Düsseldorf.

BACKGROUND: The German ophthalmological training is still a very individually organized system with only one final oral examination at the end of the 5-year residency. At the beginning of 2013 a new residency program was introduced at the department of ophthalmology of the Heinrich-Heine University Duesseldorf. This study evaluated the resident satisfaction with the new concept. MATERIAL AND METHODS: The new residency program consists of three main changes: firstly a structured training with fixed rotation in the various subdisciplines of ophthalmology, secondly a list of practical skills examinations that has to be completed during the 5-year program and thirdly annual intermediate oral examinations. The satisfaction of the residents with the new program was anonymously evaluated with a Likert scale-based questionnaire with 15 items and additional free text comments. RESULTS: (1) The structured training was mostly rated positively and 9 out of 12 of residents favored a continuation of the training concept in this form. (2) Only 7 out of 11 residents (64 %) wanted to continue the practical skills examinations in this form and only approximately half of the residents saw a positive effect of these examinations. (3) Regarding the annual examinations 8 out of 11 residents (73 %) reported that the examinations helped them to assess their skills better, 91 % (10 out of 11) reported a learning motivation, 90 % (9 out of 10) an improvement in learning due to the examinations and 73 % (8 out of 11) were of the opinion that the examinations should take place regularly. DISCUSSION: The structured training and the annual examinations were positively evaluated. These changes could be effectively implemented even with a relatively small personnel structure. In comparison the practical skill examinations were rated relatively negatively, probably because of the further increase of daily work. The number of skills to be demonstrated is currently reduced and the integration of testing into the clinical routine of examiners and examinees is under revision.

Topical ophthalmic antimicrobials: unfulfilled demands and possibility of new investments in Brazil and in the United States

In general, topical ophthalmic drug products, especially those used for treating infections, present low effectiveness because of various reasons, from unfavorable drug physicochemical properties to physiological protective mechanisms of the eye. The fact is such group of products holds room for improvement, which could mean the development of better drugs or dosage forms. To achieve this, the knowledge of market composition is essential. The present work studied and compared the antimicrobial ophthalmic markets of Brazil and of the United States (US). Official databank of Brazilian Health Regulatory Agency and of US Food and Drug Administration were assessed for registered antimicrobial topical ophthalmic drug products. Brazilian market has registered greater number of drug products (119) than the US (94), but the latter involves more variety of substances and dosage forms. In both countries, non-innovative products registered as solutions of antibacterials, especially fluoroquinolones and aminoglycosides lead the market. Despite the clinical demand, the US has only one group of antimycotics (polyenes) registered, while in Brazil, there is not any ophthalmic antimycotic product marketed. This study evidences there is not only space for development of newer drugs and formulations but also a demand for already existing technologies and products in both countries.

Towards patient self-triage in the ophthalmic emergency department: sensitivity and specificity of a self-triage instrument.

PURPOSE: Trained ophthalmic triage staff may not constantly be available in the emergency department of a specialized ophthalmic hospital, particularly at night. To support the current triage process, the aim of this study was to develop an ophthalmic instrument of patient self-triage (ISET). METHODS: A preliminary ISET, in the form of a pen-and-paper questionnaire, was refined and validated in a two-step procedure. In a first explorative step, we compared the results of the ISET with the results of the regular triage process during the day, that is, triage by a trained triage assistant in a specialized ophthalmic hospital. As several patients needed guidance completing the questionnaire, the ISET was subsequently refined. The second step was to test the validity of the refined ISET by again comparing the outcome of this triage with that of the triage assistant in the emergency department. RESULTS: The first explorative step involved 279 patients and the final validation step 298. During the validation step, sensitivity of the ISET was 94.3% and specificity 76.4%. CONCLUSION: The results show that the ISET is a sensitive and specific instrument for ophthalmic triage compared with a trained ophthalmic triage assistant.

Comparing methodologies for imputing ethnicity in an urban ophthalmology clinic.

PURPOSE: To compare methodologies for imputing ethnicity in an urban ophthalmology clinic. METHODS: Using data from 19,165 patients with self-reported ethnicity, surname, and home address, we compared the accuracy of three methodologies for imputing ethnicity: (1) a surname method based on tabulation from the 2000 US Census; (2) a geocoding method based on tract data from the 2010 US Census; and (3) a combined surname geocoding method using Bayes' theorem. RESULTS: The combined surname geocoding model had the highest accuracy of the three methodologies, imputing black ethnicity with a sensitivity of 84% and positive predictive value (PPV) of 94%, white ethnicity with a sensitivity of 92% and PPV of 82%, Hispanic ethnicity with a sensitivity of 77% and PPV of 71%, and Asian ethnicity with a sensitivity of 83% and PPV of 79%. Overall agreement of imputed and self-reported ethnicity was fair for the surname method (κ 0.23), moderate for the geocoding method (κ 0.58), and strong for the combined method (κ 0.76). CONCLUSION: A methodology combining surname analysis and Census tract data using Bayes' theorem to determine ethnicity is superior to other methods tested and is ideally suited for research purposes of clinical and administrative data.