Uveoscleral Outflow Routes after MicroPulse Laser Therapy for Refractory Glaucoma: An Optical Coherence Tomography Study of the Sclera.

To analyze in vivo scleral changes induced by MicroPulse transscleral laser therapy (MP-TLT) in refractory glaucoma using anterior segment-optical coherence tomography (AS-OCT). Forty-two candidate patients for MP-TLT were consecutively enrolled and underwent AS-OCT at baseline and after six months. MP-TLT success was defined as an intraocular pressure (IOP) reduction by one-third. The main outcome measures were the mean superior (S-), inferior (I-), and total (T-) intra-scleral hypo-reflective space area (MISHA: mm2) and scleral reflectivity (S-SR, I-SR, T-SR; arbitrary scale) as in vivo biomarkers of uveoscleral aqueous humor (AH) outflow. The IOP was the secondary outcome. The relations between the baseline-to-six months differences (D) of DS-MISHA, DI-MISHA, and DT-MISHA and DS-SR, DI-SR, DT-SR, and DIOP, were investigated. At 6 months, the median IOP reduction was 21% in the failures and 38% in the successes. The baseline S-MISHA, I-MISHA, and T-MISHA did not differ between the groups, while S-SR and T-SR were higher in the successes (p < 0.05). At six months, successful and failed MP-TLTs showed a 50% increase in S-MISHA (p < 0.001; p = 0.037), whereas I-SR and T-SR reduced only in the successes (p = 0.002; p = 0.001). When comparing DS-MISHA, DI-MISHA, and DT-MISHA and DS-SR, DI-SR, and DT-SR, there were no significant differences between the groups. In the successful procedures, DIOP was positively correlated with DT-MISHA and DI-MISHA (ρ = 0.438 and ρ = 0.490; p < 0.05). MP-TLT produced potentially advantageous modifications of the sclera in refractory glaucoma. Given the partial correlation between these modifications and post-treatment IOP reduction, our study confirmed that the activation of the uveoscleral AH outflow route could significantly contribute to the IOP lowering after MP-TLT.

Two-dimensional elastic distribution imaging of the sclera using acoustic radiation force optical coherence elastography.

The scleral elasticity is closely related with many ocular diseases, but the relevant research is still insufficient. Here, we utilized optical coherence elastography to carefully study biomechanical properties of the sclera at different positions and under different intraocular pressures. Meanwhile, elastic wave velocity and Young's modulus of each position were obtained using a phase velocity algorithm. Accordingly, the two-dimensional elasticity distribution image was achieved by mapping the Young's modulus values to the corresponding structure based on the relationship between the position and its Young's modulus. Therefore, elastic information in regions-of-interest can be read and compared directly from the scleral structure, indicating that our method may be a very useful tool to evaluate the elasticity of sclera and provide intuitive and reliable proof for diagnosis and research.

Assessment of conjunctival, episcleral and scleral thickness in healthy individuals using anterior segment optical coherence tomography.

PURPOSE: To determine the thickness of the conjunctiva, episclera and sclera in healthy individuals using anterior segment optical coherence tomography (AS-OCT). METHODS: We prospectively included 107 healthy individuals of different age groups (18-39 years, 40-54 years, 55-69 years and ≥70 years). For each eye, AS-OCT scans of four quadrants (temporal, nasal, superior and inferior) were acquired. The thickness of the conjunctiva, episclera and sclera was measured for each scan. In addition, the axial length of both eyes was measured, and general characteristics, including smoking, allergies and contact lens use, were collected. RESULTS: The mean conjunctival thickness was significantly different between the nasal and superior quadrants (87 ± 30 µm vs. 77 ± 16 µm; p < 0.001), as well as the superior and inferior quadrants (77 ± 16 µm vs. 86 ± 19 µm; p = 0.001). The mean episcleral thickness was larger in the superior (174 ± 54 µm) and inferior (141 ± 43 µm) quadrants, compared to the nasal (83 ± 38 µm) and temporal quadrants (90 ± 44 µm). The mean scleral thickness of the inferior quadrant was the largest (596 ± 64 µm), followed by the nasal (567 ± 76 µm), temporal (516 ± 67 µm) and superior (467 ± 52 µm) quadrants (all p < 0.001). The averaged scleral thickness increased 0.96 µm per age year (0.41-1.47 µm, p < 0.001). CONCLUSIONS: This study provides an assessment of the thickness of scleral and adjacent superficial layers in healthy individuals determined on AS-OCT, which could enable future research into the use of AS-OCT in diseases affecting the anterior eye wall.

Non-invasive Measurement of the Viscoelasticity of the Optic Nerve and Sclera for Assessing Papilledema: A Pilot Clinical Study.

OBJECTIVE: The purpose of this study was to evaluate our novel ultrasound vibro-elastography (UVE) technique for assessing patients with papilledema by non-invasively measuring shear wave speed (SWS), elasticity and viscosity properties of the optic nerve and sclera. METHODS: Shear wave speeds were measured at three frequencies-100, 150 and 200 Hz-on the optic nerve and sclera tissues for assessing patients with papilledema resulting from idiopathic intracranial hypertension (IIH). The method was evaluated in six papilledema patients and six controls on two separate locations for each participant (i.e., optic nerve and posterior sclera). SWSs of the optic nerve and sclera were analyzed by using a 2-D speed map technique within a circular region of interest (ROI) (i.e., the diameter of the ROI was 1.5 mm × 3.0 mm at the optic nerve and sclera, respectively). Elasticity and viscosity were then analyzed using the wave speed dispersion over the three frequencies. RESULTS: We measured values of SWS at both locations, optic nerve and sclera, of the right eye and left eye at three different frequencies in IIH patients and controls. The SWS (mean ± standard deviation [m/s]) of the right eye was significantly higher at the sclera in IIH patients compared with controls (i.e., patients vs. controls: 5.91 ± 0.54 vs. 3.86 ± 0.56, p < 0.0001 at 100 Hz), but there was no significant difference at the optic nerve (i.e., patients vs. controls: 3.62 ± 0.39 vs. 3.36 ± 0.35, p = 0.1100 at 100Hz). We observed increased elasticity (kPa) in IIH patients, indicating there are significant differences in elasticity between patients and controls at the optic nerve and sclera (i.e., right eye [patients vs. controls]: 14.42 ± 6.59 vs. 6.5 ± 5.71, p = 0.0065 [optic nerve]; 33.04 ± 10.62 vs. 9.16 ± 7.15, p < 0.0001 [sclera]). Viscosity was also (Pa·s) higher in the sclera and optic nerve of the left eye (i.e., left eye [patient vs. control]: 8.89 ± 4.37 vs. 7.27 ± 5.01, p = 0.3790 (optic nerve); 16.05 ± 10.79 vs. 8.49 ± 6.09, p < 0.0194 [sclera]). CONCLUSION: This research illustrates the feasibility of using our UVE system to evaluate stiffness of different tissues in the eye non-invasively. It suggests that the viscoelasticity of the posterior sclera is higher than that of the optic nerve. We found that the posterior sclera is stiffer than the optic nerve in patients with papilledema resulting from IIH, making UVE a potential non-invasive technique for assessing papilledema.

Usefulness of intraoperative optical coherence tomography to minimize the intraocular lens tilt during the intrascleral fixation: a clinical and experimental evaluation.

To report the usefulness of intraoperative real-time adjustment of intraocular lens (IOL) tilt during the intrascleral fixation with intraoperative optical coherence tomography (iOCT) as a clinical evaluation and investigate the factors contributing to IOL tilt using iOCT as an experimental evaluation. Retrospective cohort study and experimental research. As a clinical evaluation, the medical records of 43 eyes of 41 patients who underwent intrascleral IOL fixation combined with real-time iOCT observation were retrospectively reviewed. As an experimental evaluation, in order to investigate the factors contributing to IOL tilt, the four experiments were performed using iOCT. The mean IOL tilt angle (°) at the end of surgery and 3 months after surgery were 1.81 ± 1.15 and 2.10 ± 1.66, respectively (p = 0.46). No apparent intra- or postoperative complications occurred during the follow-up period. The experimental evaluation indicated that the IOL tilt was influenced by the insertion angle of the haptic in the vertical direction. The mean IOL tilt angle (°) was 1.94 ± 0.09, 4.67 ± 0.11, 8.90 ± 0.11, and 15.78 ± 0.85 when the insertion angle of the haptic was 0°, 10°, 27.5°, and 45° in the vertical direction, respectively (p < 0.01). Clinical and experimental IOL tilt assessment using iOCT is interactively useful for better quality surgery and better postoperative outcome.

SCLERAL EXCAVATION AT OBLIQUE MUSCLE INSERTIONS: IMAGING CHARACTERISTICS AND CORRELATION WITH SCLERAL PLAQUES AND SCLEROCHOROIDAL CALCIFICATION.

PURPOSE: To compare the imaging features of lesions showing hyporeflective posterior scleral excavation found near the insertions of the oblique extraocular muscles to the features and the natural course of Cogan scleral plaques. METHODS: Multimodal imaging with color fundus photography, spectral-domain optical coherence tomography (OCT), swept-source optical coherence tomography, and B-scan ultrasonography. RESULTS: A 71-year-old man and an 89-year-old man presented with ring-shaped hypopigmented lesions measuring between 200 µm and 300 µm transversally, and located along the superior vascular arcade and temporal to the fovea. All lesions were identified near the insertion of oblique muscles, with one observed in the temporal macula, and two found along the superotemporal arcades. Enhanced depth imaging-optical coherence tomography showed hyporeflective boat-shaped areas of scleral excavation with reduced choroidal thickness along their margins. B-scan ultrasonography showed the lesions to be intensely reflective with varying degrees of posterior shadowing. CONCLUSION: To our knowledge, this is the first report of excavated hyporeflective scleral lesions found near the oblique muscle insertions. Imaging and clinical data support the diagnosis of a posterior form of Cogan scleral plaque and are consistent with the natural course of this entity.

[Morphological evaluation of the results of laser activation of scleral hydropermeability in the treatment of glaucoma]. / Morfologicheskaya otsenka rezul'tatov operatsii lazernoi aktivatsii gidropronitsaemosti sklery v lechenii glaukomy.

PURPOSE: The study attempted to experimentally substantiate the possibility of using the laser activation of scleral hydropermeability (LASH) technique in glaucoma treatment by morphological evaluation of treatment outcomes. MATERIAL AND METHODS: The pulsed-periodic radiation from an Er-glass fiber laser (λ=1.56 µm) was used. The model experiment consisted of evaluating ultrafiltration of fluid through the tissues of human sclera autopsy specimen according to the original technique using neodymium chloride-based labeling agent and scanning electron microscopy. The clinical part of the study consisted of optical coherence tomography (OCT) and laser confocal microscopy of the sclera and conjunctiva (CMSC) performed in vivo immediately after laser treatment in the laser application sites in 5 patients (5 eyes) aged 57 to 68 years with uncompensated advanced (IIIb-c) stage of glaucoma who had previously underwent LASH surgery. RESULTS: Results of morphological evaluation after LASH revealed structural changes indicating increased transscleral ultrafiltration: increased intrastromal hyporeflective areas in the sclera, thinning of collagen fibers, formation of porous structures. Using an original technique involving neodymium chloride-based labeling agent and scanning electron microscopy, we were able to prove the enhancement of transscleral ultrafiltration. The results of the experiment were confirmed by in vivo OCT images of the sclera and CMSC performed in 5 patients with advanced glaucoma after LASH surgery, in which tissue decompaction in the laser-exposed areas was clearly visualized. CONCLUSION: The revealed structural changes indicate the possibility of reducing intraocular pressure after LASH by the means of forming scleral porous structures and increasing transscleral ultrafiltration. Experimentally selected optimal mode of laser exposure (0.66 W with total exposure time of 6 seconds) during LASH helps avoid gross destructive changes in the eye tissues, making the proposed intervention a sparing approach to the treatment of glaucoma.

[Clinical outcomes of laser activation of hydraulic permeability of the sclera in the treatment of advanced glaucoma]. / Klinicheskie rezul'taty lazernoi aktivatsii gidropronitsaemosti sklery v lechenii patsientov s dalekozashedshei stadiei glaukomy.

PURPOSE: This study evaluates the hypotensive effect and the outcomes of intravital morphological changes in the intervention site after laser activation of scleral hydro-permeability (LASH) by pulsed-periodic radiation from an Er-glass fiber laser (λ=1.56 µm) in patients with advanced glaucoma. MATERIAL AND METHODS: LASH surgery was performed in 19 patients (19 eyes) aged 48 to 73 years with uncompensated advanced stage (IIIb-c) glaucoma. In addition to standard methods of investigation, all patients were examined with optical coherence tomography (OCT) and laser confocal microscopy of sclera and conjunctiva (CMSC) at the laser treatment sites, and electronic tonography. RESULTS: The hypotensive effect after LASH in patients with advanced glaucoma was observed in 94.7% (n=18) of cases. The decrease in intraocular pressure (IOP) averaged 24.4% from baseline one month after intervention and 32.96% after six months of follow-up. In 15.7% (n=3) of cases, the recorded IOP decrease was insufficient as its target values were not achieved. However, in the vast majority of patients (n=16), the recorded IOP decrease corresponded to the target values and indicated compensation of the process. Results of complex morphological evaluation after LASH revealed structural changes indirectly indicating possible laser-induced influence on the processes of increased transscleral filtration and uveoscleral outflow. A high positive correlation dependence (r=0.848) was also revealed between the degree of IOP lowering and the increase in the coefficient of ease of aqueous humor outflow, attesting to the fact that IOP lowering was mainly due to the improvement of intraocular fluid outflow. CONCLUSION: The demonstrated efficacy of LASH technology indicates the possibility of its successful application as an independent method of IOP reduction in patients with advanced glaucoma.

The corneo-scleral junction assessed with optical coherence tomography.

PURPOSE: To evaluate corneo-scleral junction (CSJ) using anterior segment optical coherence tomography (AS-OCT) and describe the pattern of cornea and sclera interfusion based on tissue reflectivity. METHODS: This prospective observational study enrolled candidates for vision correction. Eyes with previous ocular surgery or irregular corneas were excluded. Temporal and nasal CSJ width and reflectivity patterns were assessed with AS-OCT horizontal scans. Correlations between manual and automated variables and multivariate linear regression analyses with age and spherical equivalent were performed. RESULTS: 101 right eyes were analysed. Temporal CSJ was wider (median 1.62; 1.13 to 2.22 mm) compared to the nasal side (median 1.18; 0.73 to 1.80 mm) (p<.0001). The temporal CSJ width showed negative correlation with ipsilateral anterior chamber angle measurements and positive correlation with horizontal visible iris diameter (HVID). These relationships were not statistically significant for the nasal CSJ width. No significant correlations with age or refractive error were observed at both sides. The pattern of temporal CSJ reflectivity was mostly V- or U-shaped. The eyes with V-shaped temporal CSJ had significantly larger HVID than the eyes with irregular temporal CSJ. The nasal CSJ presented irregular reflectivity in 47% of cases. CONCLUSIONS: The temporal CSJ was wider and had regular (V or U-shaped) reflectivity patterns, while nasal CSJ was narrower and more irregular. The CSJ width was independent of age and refractive error and could not be predicted from other parameters. The HVID measurement accuracy may benefit from CSJ analysis based on AS-OCT.

Integrated Intraoperative Optical Coherence Tomography during Scleral Pass in Strabismus Surgery.

We describe a novel application of integrated intraoperative OCT (iiOCT) to strabismus surgery during the scleral pass and demonstrate it to be a useful tool. A number of complications can arise from inappropriate scleral pass depth during strabismus surgery, leading to an increased risk of unwanted complications including endophthalmitis, retinal detachment, and a lost or slipped muscle. Our study demonstrated that the use of iiOCT provides easy to interpret, real-time feedback to the strabismus surgeon and may translate to safer, more consistent scleral suturing during strabismus surgery and strabismus surgical training. .

Fungal Necrotizing Scleritis After Intravitreal Injection Therapy.

PURPOSE: To report a case of infectious necrotizing scleritis secondary to Aspergillus terreus after intravitreal injection therapy. METHODS: This is a case report with literature review. RESULTS: A 98-year-old woman receiving intravitreal aflibercept injections for neovascular age-related macular degeneration in the left eye presented with severe pain, redness, and purulent discharge at the injection site. She was initially treated with topical fortified antibiotics, and clinical improvement was achieved, although microbial cultures showed negative results. Two months later, she presented with severe ocular pain and was diagnosed with anterior necrotizing scleritis. Scleral scrapings were collected for cultures, and intensive topical antibiotic therapy was reintroduced. Evaluation for autoimmune etiology and microbiological testing showed negative results. Because of the progression of the scleral necrotic area, empirical therapy with topical voriconazole was initiated, and surgical debridement was performed. Finally, the culture was positive for A. terreus. The modified therapy consisted of topical voriconazole and oral voriconazole for 3 months with an excellent clinical outcome. CONCLUSIONS: To our knowledge, this is the first case of fungal necrotizing scleritis secondary to intravitreal injection. Diagnosis was delayed due to its chronic clinical course and the slow fungal growth in culture media, but the combined medical and surgical approach resulted in a satisfactory outcome.

[Application of Ultrasound Biomicroscopy in Longterm Follow-up Post Modified CO2 Laser-assisted Sclerectomy Surgery].

Objective To observe the role of ultrasound biomicroscopy(UBM)in two-year post-operative follow-up for primary open-angle glaucoma patients with modified CO2 laser-assisted sclerectomy surgery(CLASS).Methods This was a case series study.A combination of modified CLASS and preoperative laser iris management was administered to 28 eyes.Visual acuity,intraocular pressure(IOP),and slit-lamp examinations,visual field testing,and gonioscopy were carried out at baseline and until 24 months postoperatively.UBM examination was performed at 1,3,12 and 24 months postoperatively.Results Compared with the mean preoperative IOP [(30.61±10.59)mmHg],the IOP at each time point after operation was significantly lowered [(15.15±5.87),(12.56±3.24),(13.15±2.73),(13.75±2.55)and(13.75±2.46)mmHg at 1,3,6,12 and 24 months,respectively;all P<0.001].Complete success rates and qualified success rates at 12 months and 24 months were 60.71%,89.29% and 53.57%,85.71%,respectively.UBM images can present "dolphin head sign" after successful CLASS.The thickness of trabeculo-Descemet's window was(0.13±0.03)mm,which had no significant correlation with postoperative IOP at 12(r=-0.278,P=0.144)and 24 months(r=0.026,P=0.895).UBM examination revealed a severe scleral lake diminution(a change > 50%)in 1 eye(3.57%)at 12 months and 3 eyes(10.71%)at 24 months.There was no statistical significance detected between the size of the scleral lake and IOP after CLASS.Non-founctional blebs were found in 16 eyes(57.14%)at 12 months and 25 eyes(89.28%)at 24 months.Two eyes(7.14%)demonstrated severe peripheral anterior synechiae at 24 months,requiring surgical intervention.Conclusions UBM can effectively observe the morphology of the scleral lake,anterior chamber angle and filtering blebs in post-operative follow-up after modified CLASS,and give early warning of complications.It plays an important role in ensuring the success of CLASS.

Offset of openings in optic nerve head canal at level of Bruch's membrane, anterior sclera, and lamina cribrosa.

We compared the central retinal vascular trunk (CRVT) position, as a surrogate of lamina cribrosa (LC) offset, with the anterior scleral opening (ASCO) offset from the Bruch's membrane opening (BMO). Based on the BMO-centered radial scans, the BMO and ASCO margins were demarcated, and each center was determined as the center of the best-fitted ellipse for each margin. The ASCO/BMO offset was defined as the offset between each center. Angular deviations and the extent of ASCO and CRVT offsets from the BMO center were compared directly. Incomplete demarcation of ASCO was found in 20%, which was associated with a larger BMO area and a larger ASCO offset from the BMO. The angular deviation of ASCO offset was associated with that of CRVT offset and that of the longest externally oblique border. The ASCO offset was smaller than the CRVT offset, and, unlike the CRVT offset, it was rarely deviated to the inferior side. The complete ASCO margin might not be demarcatable when determined on BMO-centered radial scans in the presence of an offset. Also, the ASCO, which reflects only the superficial scleral layer, might not reflect the LC position, because the LC might be shifted further from the ASCO.

Safety and Efficacy of Current Sclera Fixation Methods for Intraocular Lenses and Literature Overview. / Sicherheit und Effektivität von aktuellen Sklerafixationstechniken für intraokulare Linsen und Literaturübersicht.

BACKGROUND: Evaluation of the three currently most common techniques for intraocular lens (IOL) sclera fixation: (1) Prolene suture with Hoffman sclera pocket (2) four-point GoreTex suture technique (3) sutureless flanged intrascleral IOL fixation with double-needle ("Yamane") technique. MATERIAL AND METHODS: Retrospective, clinical case series (chart review) at the Department of Ophthalmology, Ludwig-Maximilians-University (LMU), Munich, Germany. Enrolled in the study were 51 patients with 55 eyes. Best-corrected visual acuity (BCVA); manifest refraction (OR); corneal tomography (central corneal thickness, CCT); biometry; central macular thickness (CMT) by optical coherence tomography (OCT); intraocular pressure (IOP); and IOL type and IOL power were recorded and compared prior to and 3 - 12 months post IOL sclera fixation surgery. Pre- and postsurgery difference analysis was performed by Wilcoxon rank sum testing (z). RESULTS: Intrascleral fixation by GoreTex suture was performed in 14 (25.5%) eyes, by Prolene suture in 19 (34.5%,) and by Yamane technique in 22 (40.0%) eyes. Within the 3 - 12 months follow-up post scleral fixation, a total of 2 (14.3%) eyes from the GoreTex, 3 (15.8%) from the Prolene and 1 (4.5%) eye from the Yamane group required refixation. Pre- and post-surgery analysis revealed a statistically significant difference in the total patient population BCVA (exact Wilcoxon test: z = - 3.202; p = 0.001; n = 55) and the Yamane subgroup (exact Wilcoxon test: z = - 2.068; p = 0.001; n = 22). The GoreTex (n = 14) and Prolene (n = 19) subgroups revealed no statistically significant differences versus preoperative baseline. Across groups, there was no statistically significant difference in IOP, CMT, and CCT. No retinal complications were observed, neither intraoperatively nor during follow-up. CONCLUSION: The volume of IOL revision surgery is increasing. Often, the only option left for visual rehabilitation is scleral IOL fixation. All three scleral fixation techniques studied demonstrated a good safety profile with no statistically significant impact on IOP, CMT, CCT, but with a notable revision rate. Visual rehabilitation to preoperative baseline levels (GoreTex [n = 14] and Prolene [n = 19]) and a statistically significant increase in visual acuity (total cohort [n = 55] and Yamane [n = 22]) seems possible. Unlike iris fixation, scleral fixation is surgically more complex and the surgeon must master a steeper learning curve.

Diagnostic imaging versus surgical procedure: intra- and postoperative OCT evaluation of sutureless scleral-fixated intraocular lens implantation and possible related complications.

Because the popularity of corneal refractive surgery has been increasing throughout the last 25 years, many authors have thought to apply optical coherence tomography (OCT) to the anterior segment (AS-OCT); by revising the instrumentation needed and slightly improve the technique, it has become an element of vital importance in order to ensure a complete and exhaustive pre- and postsurgical evaluation. Many applications of OCT have been recently developed-mostly in cataract surgery due to the increasing numbers-such as chamber biometry, which is used in a preoperative stage to determine the details of IOL implantation, and lens evaluation. The aim of this review is to assess the applications of anterior segment OCT in dislocated IOL and/or capsular bag exchange surgery with scleral sutureless fixated intraocular lens and monitoring of possible postoperative complications.

Integrated Intraoperative Optical Coherence Tomography in Pediatric Glaucoma Surgery.

The advent of integrated intraoperative optical coherence tomography (i2OCT) has opened the door for safer and more complex surgeries in the retina and cornea. However, to limit its use to just two subspecialties within ophthalmology is an opportunity lost for many other subspecialties. Here, we describe the use of i2OCT in pediatric glaucoma surgery. It can be used to identify Schlemm's canal, Barkan's membrane, demonstrate the corneal pathology in Haab's striae, and iris hypoplasia in cases of Axenfeld-Rieger anomaly. It can help identify drainage blebs that are filtering and those that are not, and identify successful drainage tube flushing. It has also been used to identify a ligating suture effect on a drainage tube. We describe these scenarios in relation to training and augmenting surgical techniques.

Screening and identifying hepatobiliary diseases through deep learning using ocular images: a prospective, multicentre study.

BACKGROUND: Ocular changes are traditionally associated with only a few hepatobiliary diseases. These changes are non-specific and have a low detection rate, limiting their potential use as clinically independent diagnostic features. Therefore, we aimed to engineer deep learning models to establish associations between ocular features and major hepatobiliary diseases and to advance automated screening and identification of hepatobiliary diseases from ocular images. METHODS: We did a multicentre, prospective study to develop models using slit-lamp or retinal fundus images from participants in three hepatobiliary departments and two medical examination centres. Included participants were older than 18 years and had complete clinical information; participants diagnosed with acute hepatobiliary diseases were excluded. We trained seven slit-lamp models and seven fundus models (with or without hepatobiliary disease [screening model] or one specific disease type within six categories [identifying model]) using a development dataset, and we tested the models with an external test dataset. Additionally, we did a visual explanation and occlusion test. Model performances were evaluated using the area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and F1* score. FINDINGS: Between Dec 16, 2018, and July 31, 2019, we collected data from 1252 participants (from the Department of Hepatobiliary Surgery of the Third Affiliated Hospital of Sun Yat-sen University, the Department of Infectious Diseases of the Affiliated Huadu Hospital of Southern Medical University, and the Nantian Medical Centre of Aikang Health Care [Guangzhou, China]) for the development dataset; between Aug 14, 2019, and Jan 31, 2020, we collected data from 537 participants (from the Department of Infectious Diseases of the Third Affiliated Hospital of Sun Yat-sen University and the Huanshidong Medical Centre of Aikang Health Care [Guangzhou, China]) for the test dataset. The AUROC for screening for hepatobiliary diseases of the slit-lamp model was 0·74 (95% CI 0·71-0·76), whereas that of the fundus model was 0·68 (0·65-0·71). For the identification of hepatobiliary diseases, the AUROCs were 0·93 (0·91-0·94; slit-lamp) and 0·84 (0·81-0·86; fundus) for liver cancer, 0·90 (0·88-0·91; slit-lamp) and 0·83 (0·81-0·86; fundus) for liver cirrhosis, and ranged 0·58-0·69 (0·55-0·71; slit-lamp) and 0·62-0·70 (0·58-0·73; fundus) for other hepatobiliary diseases, including chronic viral hepatitis, non-alcoholic fatty liver disease, cholelithiasis, and hepatic cyst. In addition to the conjunctiva and sclera, our deep learning model revealed that the structures of the iris and fundus also contributed to the classification. INTERPRETATION: Our study established qualitative associations between ocular features and major hepatobiliary diseases, providing a non-invasive, convenient, and complementary method for hepatobiliary disease screening and identification, which could be applied as an opportunistic screening tool. FUNDING: Science and Technology Planning Projects of Guangdong Province; National Key R&D Program of China; Guangzhou Key Laboratory Project; National Natural Science Foundation of China.

Deep Learning Algorithm for Automated Detection of Polycystic Ovary Syndrome Using Scleral Images.

The high prevalence of polycystic ovary syndrome (PCOS) among reproductive-aged women has attracted more and more attention. As a common disorder that is likely to threaten women's health physically and mentally, the detection of PCOS is a growing public health concern worldwide. In this paper, we proposed an automated deep learning algorithm for the auxiliary detection of PCOS, which explores the potential of scleral changes in PCOS detection. The algorithm was applied to the dataset that contains the full-eye images of 721 Chinese women, among which 388 are PCOS patients. Inputs of the proposed algorithm are scleral images segmented from full-eye images using an improved U-Net, and then a Resnet model was applied to extract deep features from scleral images. Finally, a multi-instance model was developed to achieve classification. Various performance indices such as AUC, classification accuracy, precision, recall, precision, and F1-score were adopted to assess the performance of our algorithm. Results show that our method achieves an average AUC of 0.979 and a classification accuracy of 0.929, which indicates the great potential of deep learning in the detection of PCOS.

Surgical site characteristics after CLASS followed by ultrasound biomicroscopy and clinical grading scale: a 2-year follow-up.

OBJECTIVE: This study describes the imaging of the filtering area in CO2 laser-assisted sclerectomy surgery (CLASS) using ultrasound biomicroscopy (UBM) combined with the Indiana Bleb Appearance Grading Scale (IBAGS) and evaluates the mechanism by which CLASS lowers the intraocular pressure (IOP). METHODS: Twenty-eight cases (28 eyes) of primary open-angle glaucoma that could not be controlled by drugs underwent CLASS. At 1, 3, 6, 12, 18, and 24 months after surgery, IBAGS was used to evaluate the external morphology of the filtering blebs, and UBM was used to describe and measure their internal structure. RESULTS: During the early period after CLASS, most cases showed diffuse filtering blebs with a serious degree of congestion. At the end of follow-up, most cases did not present filtering blebs. All patients showed an intact and thin trabeculodescemetic membrane (TDM) with an average thickness of 0.094 ± 0.017 mm. The scleral reservoir size gradually decreased over time and tended to stabilize after 18 months. At 3 and 6 months after surgery, 53.57% of the patients had abnormalities in the TDM area, and after laser goniopuncture treatment, the scleral reservoir became slightly larger and the IOP decreased. The TDM thickness was not correlated with postoperative IOP, and the scleral reservoir size was negatively correlated with IOP. CONCLUSION: During the early phase after CLASS, the subconjunctival and suprachoroidal pathways may be the main mechanisms lowering IOP; over time, internal drainage pathways such as the intrascleral, trabecular-meshwork, and suprachoroidal pathways play greater roles in lowering IOP.

MULTIPLE INTRAVITREAL INJECTIONS DO NOT CAUSE ANTERIOR SCLERAL THINNING: An Ultrasound Biomicroscopy Study.

PURPOSE: To evaluate possible changes in anterior scleral thickness and structure and changes in the anterior segment in eyes receiving multiple intravitreal injections using ultrasound biomicroscopy imaging. METHODS: Prospective, interventional, nonrandomized, cross-sectional study. Both eyes from 33 patients previously treated at least by 15 intravitreal injections in one eye only for retinal diseases were included. Intravitreal injections were performed by ophthalmologists using an aseptic standardized procedure. Ultrasound biomicroscopy examination was performed in all eyes, and scleral thickness was measured at the pars plana in four quadrants. Anterior chamber depth and ciliary body size were measured. Scleral thickness in the study eye was compared with the fellow eye. Secondary outcome measures were 1) anterior chamber depth; 2) ciliary body size; 3) scleral qualitative changes in the study eye compared with the fellow eye and 4) risk factors for scleral thinning. RESULTS: There was no statistically significant difference in scleral thickness between the study and fellow eyes when comparing each quadrant between the two eyes (P = 0.86 superotemporal; P = 0.76 superonasal; P = 0.72 inferonasal; P = 0.55 inferotemporal). Scleral thickness was neither related to the number of injections nor to the duration of treatment in the treated eye. CONCLUSION: Multiple intravitreal injections do not impact scleral thickness in a clinical practice using different injection sites.