Utility of ChatGPT for Automated Creation of Patient Education Handouts: An Application in Neuro-Ophthalmology.

BACKGROUND: Patient education in ophthalmology poses a challenge for physicians because of time and resource limitations. ChatGPT (OpenAI, San Francisco) may assist with automating production of patient handouts on common neuro-ophthalmic diseases. METHODS: We queried ChatGPT-3.5 to generate 51 patient education handouts across 17 conditions. We devised the "Quality of Generated Language Outputs for Patients" (QGLOP) tool to assess handouts on the domains of accuracy/comprehensiveness, bias, currency, and tone, each scored out of 4 for a total of 16. A fellowship-trained neuro-ophthalmologist scored each passage. Handout readability was assessed using the Simple Measure of Gobbledygook (SMOG), which estimates years of education required to understand a text. RESULTS: The QGLOP scores for accuracy, bias, currency, and tone were found to be 2.43, 3, 3.43, and 3.02 respectively. The mean QGLOP score was 11.9 [95% CI 8.98, 14.8] out of 16 points, indicating a performance of 74.4% [95% CI 56.1%, 92.5%]. The mean SMOG across responses as 10.9 [95% CI 9.36, 12.4] years of education. CONCLUSIONS: The mean QGLOP score suggests that a fellowship-trained ophthalmologist may have at-least a moderate level of satisfaction with the write-up quality conferred by ChatGPT. This still requires a final review and editing before dissemination. Comparatively, the rarer 5% of responses collectively on either extreme would require very mild or extensive revision. Also, the mean SMOG score exceeded the accepted upper limits of grade 8 reading level for health-related patient handouts. In its current iteration, ChatGPT should be used as an efficiency tool to generate an initial draft for the neuro-ophthalmologist, who may then refine the accuracy and readability for a lay readership.

Prevalence of Person-First Language in Idiopathic Intracranial Hypertension: A Systematic Review of Case Reports.

BACKGROUND: Person-first language (PFL) is a linguistic prescription, which places a person before their disease. It is considered an important tool to reduce stigma. However, PFL is not routinely used across the scientific literature, particularly in patients with overweight or obesity. Patients with idiopathic intracranial hypertension (IIH) face various stigmas through high rates of poverty, female gender, and frequent rates of comorbidities. Non-PFL language use intersects and worsen the health inequities faced by these patients. METHODS: A systematic review of case reports. MEDLINE and EMBASE were searched for all case reports with "pseudotumor cerebri" [MESH] OR "Idiopathic Intracranial Hypertension" as key word between January 1974 and August 2022. The primary criterion was the article's inclusion of patients with overweight or obesity. The secondary criterion was the article's discussion regarding obesity as risk factor. Articles not meeting primary or secondary criteria were excluded. RESULTS: Approximately 514/716 (71.8%) articles used non-PFL language. The publication year was predictive of non-PFL language: 1976-1991 (82.3%) vs 1992-2007 (72.3%, P = 0.0394) and 2008-2022 (68.3%, P = 0.0056). Non-PFL was significantly higher in obesity compared with other medical conditions (60.3% vs 7.3%, P < 0.001). The patient gender (P = 0.111) and ethnicity (P = 0.697), author's specialty (P = 0.298), and primary English-speaking status (P = 0.231), as well as the journal's impact factor (P = 0.795), were not predictive of non-PFL. CONCLUSIONS: Most literature focused on IIH use non-PFL when discussing overweight or obesity, regardless of the patient's gender and ethnicity, journal's impact factor, senior author's specialty, and English-speaking status. Non-PFL use is much more common when discussing obesity compared with other medical conditions. Appropriate use of PFL can decrease stigma and, more importantly, decrease the intersectionality of health stigma faced by patients with IIH.

A Rare ND5 Mutation Causing Leber's Hereditary Optic Neuropathy.

Mutations to the ND5 gene are uncommonly associated with Leber's hereditary optic neuropathy (LHON). Herein, we describe a 57-year-old man with the m. 13528A>G, p. (Thr398Ala) mutation at the ND5 gene who presented with progressive bilateral vision loss over the course of 3 months. He had a significant history of smoking and alcohol consumption. Visual field testing demonstrated bilateral central scotomas. At 2-year follow-up, his visual acuity improved relative to baseline and temporal optic disc pallor was observed in both eyes. There are scarce reports of this mutation in the literature, and this case report further expands the clinical presentation of the m. 13528A>G mutation at the ND5 gene in patients with LHON phenotype.

Inaccuracy of idiopathic intracranial hypertension diagnosis in case reports.

BACKGROUND: We reviewed the medical case report literature to determine the proportion of cases of idiopathic intracranial hypertension (IIH) that were either inappropriately labelled as IIH or prematurely given this diagnosis. METHODS: We searched OVID MEDLINE from 2012 to 2022 to identify case reports that diagnosed patients with IIH. Case reports were assessed for diagnostic accuracy using Friedman et al.'s revised diagnostic criteria for primary pseudotumor cerebri syndrome. Our primary outcome was the crude prevalence of inappropriate or premature IIH diagnoses. Our secondary outcome was determining if inaccurate IIH diagnoses were associated with variables such as journal subscription model and impact factor, author affiliation, country of origin, and year of publication. RESULTS: A total of 33/185 case reports (17.8%) either incorrectly labelled a patient as having IIH or did not perform all of the investigations necessary to make a diagnosis of IIH. Some of these studies (4.8%) were believed to still represent 'probable' IIH given the clinical presentation, whereas 13.0% of studies were determined to have mislabelled their patients as having IIH. The most common reason that case reports did not meet diagnostic criteria included: a lack of MRV in atypical patient cases (42.4%, n = 14), no papilledema in addition to a lack of characteristic neuroimaging features (33.3%, n = 11), intracranial hypertension being secondary to another documented cause (12.1%, n = 4), normal LP opening pressure in addition to other factors (12.1%,n = 4), no description of neuroimaging (6.1%, n = 2), and abnormal CSF composition (6.1%, n = 2). Case reports that used the term 'IIH' incorrectly had a significantly lower journal impact factor (2.0 vs. 2.6, p = 0.01). CONCLUSIONS: There is a high prevalence of premature or inappropriate diagnoses of IIH in the peer-reviewed case report literature. Adherence to published diagnostic criteria is needed when publishing IIH case reports, and authors are expected to report all relevant data in their report to ensure that an accurate diagnosis is made.

Comparison of Idiopathic Intracranial Hypertension Patients With and Without Anemia.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a condition of elevated intracranial pressure without an identifiable cause. It mostly affects young obese women but has been reported in individuals newly diagnosed with anemia or with chronic anemia. The relationship between anemia and IIH is not well elucidated. This study aims to characterize the course of IIH in anemic patients. METHODS: Consecutive patients with IIH were recruited from neuro-ophthalmology clinics. Subsequent retrospective chart review obtained information on symptoms, complete blood counts (CBCs), visual acuity, visual fields, and optic disc edema at baseline and follow-up. Anemia was diagnosed by hemoglobin <120 g/L (women) and <130 g/L (men). RESULTS: One hundred twenty-three patients with IIH were recruited for this study, and 22.8% (28/123) had anemia. More anemic individuals had mild-to-moderate visual acuity impairment (logarithm of minimum angle of resolution 0.3-1, P = 0.01) and worse automated mean deviation ( P = 0.048). The median follow-up time was 47.4 weeks (interquartile range:20.1-91.8). Fifteen of 28 patients with anemia received anemia treatment and showed a trend toward increased hemoglobin. At follow-up, there were no differences in the visual acuity, but patients with anemia had worse automated mean deviation on visual fields ( P = 0.045). CONCLUSIONS: IIH patients with anemia had worse visual function at presentation and worse final visual field parameters. This suggests that CBCs should be obtained for patients with papilledema because it may influence final visual outcome.

Comparison of pre-formalin fixation and postfixation temporal artery biopsy lengths.

OBJECTIVE: To evaluate the difference in temporal artery biopsy length before and after formalin fixation and identify any correlations with pathologic diagnosis. DESIGN: Prospective case series. PARTICIPANTS: Patients undergoing temporal artery biopsy between June 2020 and October 2021. METHODS: The pre- and postfixation biopsy lengths were compared. The primary outcome was the difference in temporal artery length as measured before fixation by the surgeon versus the postfixation measurement by the pathologist. RESULTS: Forty-seven consecutive biopsies in 46 patients were included. One patient had a repeat biopsy. Mean age was 75.3 ± 8.4 years (range, 49-94 years); 74% of patients (34 of 46 patients) were female. Mean prefixation biopsy length was 2.36 ± 0.58 cm (range, 1.1-4.5 cm). Mean postfixation biopsy length was 2.09 ± 0.59 cm (range, 0.6-3.8 cm). Mean difference (postfixation shrinkage) was 0.27 ± 0.24 cm (p = 0.0298), and 36% of biopsies (17 of 47 biopsies) were positive. There was no significant difference in prefixation temporal artery biopsy length (p = 0.38) or postfixation shrinkage (p = 0.24) between positive and negative biopsies. In a univariate analysis, elevated erythrocyte sedimentation rate was 31.3 mm/h (range, 4-88 mm/h) in negative biopsies versus 54.5 mm/h (range, 29-98 mm/h) in positive biopsies (p = 0.01), C-reactive protein was 17.4 mg/L (range, 0.2-145 mg/L) in negative biopsies versus 78.56 mg/L (range, 5-244.4 mg/L) in positive biopsies (p = 0.003), and platelets were 254.9 × 109/L (range, 134-570 × 109/L) in negative biopsies versus 393.8 × 109/L (range, 210-593 × 109/L) in positive biopsies (p < 0.001), all associated with a positive pathologic diagnosis. CONCLUSIONS: The average temporal artery biopsy was approximately 0.27 cm shorter on pathologic reports compared with before fixation measurements. Surgeons should account for this shrinkage with a buffer of at least 0.3 cm, aiming for excision of at least 2.3 cm, if they desire a postfixation size of 2 cm.

Idiopathic Intracranial Hypertension and Socioeconomic Status in the Greater Toronto Area, Canada.

BACKGROUND: Previous studies have identified an association between obesity and socioeconomic variables such as poverty, minority status, and a low level of education. Because obesity is a major risk factor for the development of idiopathic intracranial hypertension (IIH), this study aims to identify and assess relationships between socioeconomic and geographic variables in patients with IIH in Canada. METHODS: A retrospective chart review was performed to identify female patients with IIH presenting to 2 neuro-ophthalmology clinics in Toronto between 2014 and 2022. Consecutive female patients younger than 50 years who did not have IIH were identified as controls. Patient age, body mass index (BMI), and postal code were obtained from electronic medical records. Patient postal codes were then converted to geographic dissemination areas based on the 2016 Canadian census, and data on socioeconomic outcomes were collected from Statistics Canada. RESULTS: Three hundred twenty-two female patients with IIH (mean age: 32.3 ± 10) and 400 female controls (mean age: 33.9 ± 9) were included. The mean BMI was 35.0 ± 8 for patients with IIH and 26.7 ± 7 for control patients ( P < 0.00001). There was a significant difference between dissemination areas resided by patients with IIH and control patients for median income ($34640 vs $36685 CAD, P = 0.02) and rate of postsecondary degree attainment (57.7% vs 60.5%, P = 0.01). There were no significant differences in the percentage of visible minorities, percentage of immigrants, knowledge of official languages, percentage of married individuals, average household size, or unemployment rate. There was a weak but significant inverse relationship between the rate of postsecondary degree attainment in dissemination areas resided by patients with IIH and their BMI ( P = 0.01, R 2 = 0.02). CONCLUSION: Patients with IIH reside in geographic areas with lower average levels of income and education than control patients. Patients with lower levels of education may be at higher risk of elevated BMI and therefore disease incidence and progression.

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.

Anemia and Idiopathic Intracranial Hypertension: A Case-Control Study.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a condition that mostly affects obese women of childbearing age but has been reported to be temporally related to new diagnoses of anemia. Despite these reports, the association between anemia and IIH remains controversial. The present study aimed to understand the strength of association between anemia and IIH through a case-control design. METHODS: Consecutive IIH patients were recruited from neuro-ophthalmology clinics and matched by age and sex to consecutive patients attending neuro-ophthalmology clinics with diagnoses other than IIH. Complete blood counts (CBCs) were reviewed within 6 months of neuro-ophthalmology presentation, and anemia was diagnosed by hemoglobin of <120 g/L in women and <130 g/L in men. Anemia was classified as microcytic (mean corpuscular volume (MCV) < 80 fL), normocytic (MCV 80-100 fL), and macrocytic (MCV > 100 fL) as well as mild (hemoglobin >110 g/L), moderate (hemoglobin 80-109 g/L), and severe (hemoglobin <80 g/L). RESULTS: One hundred twenty-three IIH patients and 113 controls were included in the study. More IIH patients than controls had anemia (22.8%, 28/123 vs 10.6%, 12/113, P = 0.01) with an odds ratio of 2.48 (95% CI: 1.19, 5.16). There were no differences in severity of anemia or MCV between IIH patients and controls, with anemia most often being mild (57.1%, 16/28 vs 75%, 9/12) and normocytic (50.0%, 14/28 vs 50.0%, 6/12). However, 17.9% (5/28) of IIH patients had severe anemia compared with zero in the control group. IIH patients had a higher mean platelet count than controls ( P < 0.001), and there were no differences on leukocyte counts. CONCLUSION: Idiopathic intracranial hypertension patients have a higher prevalence of anemia compared with non-IIH neuro-ophthalmology patients. The anemia was mostly mild and may be explained by other factors related to worse health status and obesity, including low socioeconomic status, poor nutrition, and polycystic ovary syndrome. However, as a CBC is a widely available test and anemia may influence the IIH disease course, we propose that this test be obtained in all patients with new papilledema.

Idiopathic intracranial hypertension in atypical demographics.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a condition that most often occurs in women of reproductive age with elevated body mass index (BMI) (typical patients). Individuals outside of this demographic group (atypical patients) may have a different pathophysiology underlying raised intracranial pressure (ICP) leading to unique clinical presentations and prognosis. METHODS: Retrospective chart review of patients with IIH in typical and atypical demographic groups: men, those diagnosed at age 40 or older and those with BMI <26.0 kg/m2. RESULTS: 193 typical and 50 atypical patients with IIH were included. Age at diagnosis was higher in men and patients with normal BMI (37.2 ± 11.8 and 32.3 ± 9.8 years versus 27.3 ± 5.6 years). Older patients presented with headache less often than typical patients (42.9% versus 77.2%). Opening pressure on lumbar puncture (LP) and degree of optic disc edema were not significantly different between groups, though men had worse mean deviation (MD) on visual fields (VFs) (10.16 ± 10.40 dB versus 4.52 ± 5.53 dB in typical group). There was no significant difference between the typical and atypical groups in visual outcomes including number of patients requiring surgical treatment, development of optic atrophy and presence of persistent papilledema, though a trend toward worse VF MD was seen in men. In a pooled analysis of all patients, MD on VF at presentation was the only significant predictor of final visual outcome. CONCLUSION: Men and patients with normal BMI are diagnosed with IIH later in life. Clinical presentations of typical and atypical groups are similar, although older patients report headaches less frequently. Final visual outcomes were not significantly different between typical and atypical patients and VF loss at presentation is the most consistent predictor of final visual outcome in all patients.

Treatment and prophylaxis of radiation optic neuropathy: A systematic review and meta-analysis.

PURPOSE: Radiation optic neuropathy (RON) generally follows radiation therapy that exceed 50 Gy to the visual axis and occurs within three years of therapy. Currently, there are no universally accepted treatments or prophylaxis for RON. The review aimed to examine the efficacy of all treatments and prophylaxis for RON. METHODS: MEDLINE, Embase, the Cochrane Library, and gray literature were searched to December 2020. Studies on treatment(s) and/or prophylaxis of RON were included. Results were meta-analyzed using a random-effects model. Primary outcomes included the proportions of patients who experienced improvement, no change, or worsening of visual acuity (VA) for each treatment. Secondary outcome was the incidence of RON for studies on prophylaxis. RESULTS: Overall, 50 studies (n = 5397) were included. Meta-analysis (n = 1752) showed significantly lower incidence of RON in patients who underwent intravitreal anti-VEGF prophylaxis compared to control (RR 0.64, 95%CI [0.48, 0.86]) for uveal melanoma. Intravitreal anti-VEGF injections (n = 68), hyperbaric oxygen therapy alone (n = 14), and pentoxifylline (n = 5) resulted in improved or stable vision ≤1 logMAR in 54.5%, 42.9%, and 40.0% of patients, respectively. Systemic corticosteroids (n = 82), anticoagulants (n = 12), and systemic bevacizumab (n = 7) showed improved or stable vision ≤1 logMAR in 17.1%, 33.3%, and 14.3% of patients, respectively. Overall risk of bias was low, but evidence was limited to retrospective studies. CONCLUSION: Intravitreal anti-VEGF injections reduced incidence of RON in irradiated uveal melanoma patients. Systemic corticosteroids, systemic bevacizumab, and warfarin alone are likely ineffective treatments. Early hyperbaric oxygen therapy and intravitreal anti-VEGF injections were most effective among those investigated and require further investigation.

Idiopathic Intracranial Hypertension: Incidental Discovery Versus Symptomatic Presentation.

BACKGROUND: We aim to compare the clinical characteristics, disease course and visual outcomes between Canadian patients with idiopathic intracranial hypertension (IIH) who were incidentally discovered and those who sought care due to symptoms of IIH. METHODS: Retrospective chart review of consecutive IIH patients conducted at tertiary neuro-ophthalmology clinics. Patients were divided into Group 1 (incidentally discovered disease) and Group 2 (patients seeking medical care due to symptoms of intracranial hypertension). RESULTS: One hundred eighty-six patients were included in the study; of which, 75 (40.3%; Group-1) were incidentally discovered and 111 presented due to symptoms of IIH (Group-2). There were no differences in proportion of females (P = 0.101), age (P = 0.450), body mass index (P = 0.386), MRI findings of empty or partially empty sella (P = 0.41), and sella grade (P = 0.704). Group-1 patients were less likely to have experienced headache (P = 0.001), transient visual obscurations (P < 0.001), and diplopia (P = 0.026) at presentation. Group-1 patients were less likely to receive medical (P < 0.001) and surgical (P = 0.004) treatment. There was no difference in proportion of patients who lost weight between the groups (P = 0.848). At baseline, Group-1 patients exhibited better visual acuity (P = 0.001), Humphrey mean deviation (P < 0.001) and retinal nerve fiber layer thickness (P < 0.001). Group-1 patients continued to have better visual acuity (P = 0.002) and Humphrey mean deviation (P < 0.001) at final follow-up. CONCLUSIONS: A significant portion of IIH patients were incidentally discovered. This group exhibited a favorable prognosis and only a minority of these patients required treatment. The way in which patients enter the medical system may be a valuable way to risk stratify IIH patients.

Cilioretinal Sparing Central Retinal Artery Occlusion from Giant Cell Arteritis.

A 93-year-old woman presented with a 1-day history of sudden painless vision loss in her right eye with a background of new temporal headaches and jaw claudication. Dilated fundus examination of the right eye showed mild retinal whitening and edema throughout the right fundus with selective sparing in the distribution of the cilioretinal artery. A diagnosis of giant-cell arteritis (GCA) was made and confirmed with temporal artery biopsy. Oral prednisone was initiated and her vision improved to 20/200 in the right eye at 3-month follow-up. GCA-related cilioretinal artery sparing central retinal artery occlusion is rare and may have mild improvement with promt treatment.