A deep learning approach to hard exudates detection and disorganization of retinal inner layers identification on OCT images.

The purpose of the study was to detect Hard Exudates (HE) and classify Disorganization of Retinal Inner Layers (DRIL) implementing a Deep Learning (DL) system on optical coherence tomography (OCT) images of eyes with diabetic macular edema (DME). We collected a dataset composed of 442 OCT images on which we annotated 6847 HE and the presence of DRIL. A complex operational pipeline was defined to implement data cleaning and image transformations, and train two DL models. The state-of-the-art neural network architectures (Yolov7, ConvNeXt, RegNetX) and advanced techniques were exploited to aggregate the results (Ensemble learning, Edge detection) and obtain a final model. The DL approach reached good performance in detecting HE and classifying DRIL. Regarding HE detection the model got an AP@0.5 score equal to 34.4% with Precision of 48.7% and Recall of 43.1%; while for DRIL classification an Accuracy of 91.1% with Sensitivity and Specificity both of 91.1% and AUC and AUPR values equal to 91% were obtained. The P-value was lower than 0.05 and the Kappa coefficient was 0.82. The DL models proved to be able to identify HE and DRIL in eyes with DME with a very good accuracy and all the metrics calculated confirmed the system performance. Our DL approach demonstrated to be a good candidate as a supporting tool for ophthalmologists in OCT images analysis.

Perifoveal exudative vascular anomalous complex (PEVAC).

We present three cases of patients aged 66, 80 and 23, who presented unilateral vision loss. Optical coherence tomography (OCT) in all of them showed macular oedema and a rounded lesion with hyperreflective wall, and fluorescein angiography (FAG) in two of them showed hyperfluorescent perifoveal aneurysmal dilations with exudation. None of the cases showed response to treatment after one year of follow-up, finally being diagnosed with Perifoveal Exudative Vascular Anomalous Complex (PEVAC).

Local Triamcinolone Treatment Affects Inflammatory Response in Seroma Exudate of Abdominoplasty Patients: A Randomized Controlled Trial.

BACKGROUND: As the leading complication of abdominoplasty, seroma formation might represent an inflammatory process in response to surgical trauma. This prospective randomized trial investigated whether local administration of the antiinflammatory agent triamcinolone could prevent seroma accumulation. METHODS: Weekly and cumulative seroma volumes were compared between the study groups A, B, and C over a 4-week follow-up (group A, with drain, without triamcinolone; group B, without drain, without triamcinolone; group C, without drain, with triamcinolone). Aspirated seroma samples were analyzed by enzyme-linked immunosorbent assay for selective inflammatory mediators. RESULTS: Triamcinolone significantly reduced cumulative seroma volume (n = 60; mA 845 ± SDA 578 ml, mC 236 ± SDC 381 ml, p = 0.001). The most accentuated suppressive effect of triamcinolone was observed shortly after the treatment (week 1) (mA1 616 ± SDA1 457 ml, mB1 153 ± SDB1 161 ml, mC1 22 ± SDC1 44 ml, pA1/C1 < 0.001, pB1/C1 = 0.014). Local triamcinolone administration resulted in a differential concentration of interleukin-6 (IL-6) and matrix metalloproteinase-9 (MMP-9 (week 1) in seroma exudate as measured by enzyme-linked immunosorbent assay (mIL-6A1 1239 ± SDA1 59 pg/ml, mIL-6C1 848 ± SDC1 80 pg/ml, p < 0.001; mMMP-9A1 2343 ± SDA1 484 pg/ml, mMMP-9C1 376 ± SDC1 120 pg/ml, p = 0.001). CONCLUSIONS: Local administration of 80 mg of triamcinolone reduced postabdominoplasty seroma accumulation significantly. Under triamcinolone treatment, suppressed levels of IL-6 and MMP-9 in seroma fluid were observed. Notably, inflammatory marker suppression correlated clinically with a decrease in seroma accumulation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

ANATOMICAL CHANGES ON SEQUENTIAL MULTIMODAL IMAGING IN PERIFOVEAL EXUDATIVE VASCULAR ANOMALOUS COMPLEX.

PURPOSE: To report a series of 21 patients with perifoveal exudative vascular anomalous complex (PEVAC) and to investigate the anatomical changes over time. METHODS: We conducted a retrospective study. Clinical data of consecutive patients, presenting at the Rotterdam Eye Hospital between 2014 and 2019, were analyzed. The data collected included best-corrected visual acuity, fundus photography, optical coherence tomography (OCT), OCT-angiography, fluorescence angiography, and indocyanine green angiography. RESULTS: We included 21 patients with a PEVAC lesion with a mean follow-up of 24.3 ± 13.8 months (range, 9-46 months). Patients with PEVAC were on average 75.3 ± 11.1 years (range, 53-90 years). The large perifoveal vascular aneurysmal abnormality was associated with small retinal hemorrhages in six patients and hard exudates in three patients. The PEVAC lesion was associated with intraretinal cystic spaces on OCT in 15 patients. Twelve of 21 patients showed no changes in cystic spaces on OCT during follow-up: 9 patients had stable cystic spaces and 3 patients had no cystic spaces. In contrast, in 9 of 21 patients, we observed changes in cystic spaces on OCT during follow-up. In two patients, cystic spaces appeared during follow-up, and in seven patients, there was a spontaneous resolution of cystic spaces. In three of these seven patients, the PEVAC lesion completely disappeared. Two patients, with stable intraretinal cystic spaces on OCT, were treated with intravitreal injections of anti-vascular endothelial growth factor without improvement. CONCLUSION: Perifoveal exudative vascular anomalous complex is an idiopathic perifoveal retinal vascular abnormality that is associated with intraretinal cystic spaces. These intraretinal cystic spaces associated with a PEVAC lesion, and even the PEVAC lesion itself, can have a spontaneous resolution over time.

[Diagnosis of malignant pleural effusions using convolutional neural networks by the morphometric image analysis of facies of pleural exudate]. / Diagnostika zlokachestvennykh plevral'nykh vypotov s pomoshch'yu svertochnykh neironnykh setei putem morfometricheskogo analiza izobrazhenii fatsii plevral'nogo ekssudata.

OBJECTIVE: To estimate the possibility of diagnosis of malignant pleural effusion using convolutional neural networks of facies images of pleural exudates obtained by the method of wedge-shaped dehydration. MATERIAL AND METHODS: We studied 163 images of pleural fluid facies obtained by wedge-shaped dehydration in patients with various pleural effusions (10 nosological groups). Recognition and analysis were carried out using convolutional neural network. The images were divided into two groups - malignant effusion (n=65; 40%) and other diseases (n=98; 60%). RESULTS: There were 131 photos selected for further investigation after pre-processing of images by eliminating defective ones, turning them into black and white format, cleaning of 'noise', cutting out the facies. Then the images were standardized. The method of rigid transformations with rotation for every 10 degrees was used. As a result, their number increased up to 4,585. Self-taught neural network analyzed the images of facies independently by separation of the fragments consisting of black and white dots and comparison of them with each other. Self-teaching and training of each neural network were ensured by random sampling of 80% of images from the initial sample. Then the remaining 20% of the images were used as a control sample to assess the possibilities of recognition pleural effusion cause. Four options of convolutional neural networks were used. An accuracy of cancer detection ranged from 82% to 95.6%, benign diseases - from 84% to 94.7%. The neural network with the highest sensitivity was chosen. CONCLUSION: Automated image analysis system of pleural effusion facies using convolutional neural network ensured an accuracy of diagnosis of malignant pleural effusion in 95,6% of cases and other diseases in 90% of cases. The method is simple, efficient, cheap and reagentless.

PREDICTORS OF RECURRENT EXUDATION IN CHOROIDAL NEOVASCULARIZATION IN AGE-RELATED MACULAR DEGENERATION DURING A TREATMENT-FREE PERIOD.

PURPOSE: To investigate predictors of recurrent exudation in choroidal neovascularization (CNV) of age-related macular degeneration on optical coherence tomography angiography (OCTA) images during an anti-vascular endothelium growth factor therapy-free period. METHODS: Optical coherence tomography angiography images of 41 eyes of 41 patients with more than a 3-year history of anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration at the study baseline were evaluated retrospectively. The patients thereafter had a treatment-free period exceeding 6 months under an as-needed regimen and could be followed for an additional 6 months. RESULTS: The square root of the CNV area in 19 eyes with recurrence during the second 6-month period enlarged significantly (P = 0.036) from 2.31 ± 0.81 (mean ± SD) to 2.86 ± 0.87 mm during the treatment-free period but not in the 22 eyes without a recurrence. The percentages of branching with tiny vessels (42%) and peripheral arcades at the CNV termini (42%) were significantly (P < 0.001, respectively) higher in the recurrence group compared with the group in which the CNV was no longer active (14% and 5%, respectively). CONCLUSION: Choroidal neovascularization enlargement and features may guide treatment timing in eyes with exudative-free periods.

Rigid Mini-Thoracoscopy Versus Semirigid Thoracoscopy in Undiagnosed Exudative Pleural Effusion: The MINT Randomized Controlled Trial.

BACKGROUND: There is debate regarding the ideal instrument for medical thoracoscopy. The authors compared rigid mini-thoracoscopy with semirigid thoracoscopy for thoracoscopic pleural biopsy. METHODS: Consecutive subjects with undiagnosed exudative pleural effusion were randomized (1:1 ratio) to mini-thoracoscopy or semirigid thoracoscopy groups. The primary objective was a comparison of the diagnostic yield of pleural biopsy. Key secondary outcomes were the comparison of sedative/analgesic dose, operator-rated and patient-rated pain on visual analog scale (VAS), operator-rated overall procedural satisfaction (VAS), pleural biopsy size, and complications between the groups. RESULTS: Of the 88 screened subjects, 73 were randomized: 36 to mini-thoracoscopy and 37 to semirigid thoracoscopy. Diagnostic yield of pleural biopsy in the mini-thoracoscopy (69.4%) and semirigid thoracoscopy groups (81.1%) was similar on intention-to-treat analysis (P=0.25). Although the operator-rated overall procedure satisfaction scores were similar between groups (P=0.87), operator-rated pain [VAS (mean±SD), 43.5±16.7 vs. 31.7±15.8; P<0.001] and patient-rated pain (VAS, 41.9±17.3 vs. 32.1±16.5; P=0.02) scores were greater in the mini-thoracoscopy group. Mean dose of fentanyl and midazolam received was similar between the 2 groups (P=0.28 and 0.68, respectively). Biopsy size was larger in the mini-thoracoscopy group (16.1±4.5 vs. 8.3±2.9 mm; P<0.001). Three minor complications occurred in the mini-thoracoscopy group and 6 in the semirigid thoracoscopy group (P=0.11). There were no serious adverse events or procedure-related mortality. CONCLUSION: Diagnostic yield of rigid mini-thoracoscopy is not superior to semirigid thoracoscopy. Use of semirigid thoracoscope may provide greater patient comfort.

New Method of Quantitative Analysis of Hard Exudate Using Optical Coherence Tomography: Application in Diabetic Macular Edema.

PURPOSE: In the present study, the volume of hard exudates (HEs) was quantitatively measured using optical coherence tomography (OCT) and the agreement and correlation with area of HEs in fundus photography were analyzed. METHODS: The medical records of patients with diabetic macular edema who underwent focal laser treatment and were followed up more than 3 months were retrospectively evaluated. An automated customized program designed for measuring HE volume was used. The HEs in each OCT B-scan binary image were measured using 512 × 128 pixels, 6 mm × 6 mm OCT cube scans. The volume was measured by summing the segmented HEs in each 128 B-scan image. The area was measured in 6 mm x 6 mm fundus photography. The volume and area were measured before and 3 months after the treatment. The agreement of increase and decrease in HEs, and the correlation of volume and area of HEs were analyzed. RESULTS: A total of 35 patients (39 eyes) were included in the study. The volume was significantly reduced from 0.07978 to 0.02565 mm³ at 3 months (p < 0.001). The area was also significantly reduced from 15.35 to 8.60 mm² at 3 months (p < 0.001). The volume was decreased in 34 eyes and increased in 5 eyes. The area was decreased in 37 eyes and increased in 2 eyes. A significant correlation between volume and area was found (p < 0.001) as well as agreement between increase and decrease in volume and area. CONCLUSIONS: In the 3-dimensional quantitative volumetric analysis, the volume and area of HEs were correlated and the direction of increase and decrease was concordant. Considering the distribution of HEs in multiple layers of the retina, volumetric analysis could be considered a substitute for the analysis of HE area.

Short-Term Progression of Diabetic Hard Exudates Monitored with High-Resolution Camera.

PURPOSE: To assess the progression of diabetic hard exudates over an 8-week period, using a high-resolution adaptive optics camera. DESIGN: Prospective observational study. METHODS: Five eyes of three patients presenting diabetic maculopathy with hard exudates were studied. An area of clinically visible exudates was imaged sequentially using SD-OCT and high-resolution flood illumination adaptive optics for 2 months, on a weekly basis. A time-lapse video was obtained for each eye studied. Changes in terms of surface, number of free elements (foci), and central macular thickness were recorded. RESULTS: Short-term modifications in terms of disposition, size, and number of exudates were observed. Two patterns of progression were identified: two eyes showed exudate dislocation concomitant with the regression of the underlying macular edema, with hard exudates being progressively replaced by a multitude of smaller foci. These exudates were labeled resorption exudates. In three other eyes with persistent diabetic macular edema, foci aggregated into larger exudates. CONCLUSION: Diabetic hard exudate changes occurred over a short period of time but were not assessable clinically. Adaptive optics was able to document these subtle changes precisely. Further studies using this imaging modality may improve our understanding of the natural history of exudates and eventually help assess the efficacy of the various treatments available such as lipid-lowering drugs and anti-VEGFs injections.

Percutaneous drainage and management of fluid collections associated with necrotic or cystic tumors in the abdomen and pelvis.

PURPOSE: The purpose of the study was to evaluate the efficacy and safety of percutaneous drainage for palliation of symptoms and sepsis in patients with cystic or necrotic tumors in the abdomen and pelvis. MATERIALS AND METHODS: This is a single center retrospective study of 36 patients (18 men, mean age = 51.1 years) who underwent percutaneous drainage for management of cystic or necrotic tumors in the non-postoperative setting over an 11-year period. Nineteen patients with intraabdominal fluid collections associated with primary malignancies included: cervical (n = 7), colorectal (n = 3), urothelial (n = 3), and others (n = 6). The 17 patients with fluid collections associated with intraabdominal metastases stemmed from the following primary malignancies: oropharyngeal squamous cell carcinoma (n = 3), colorectal (n = 3), ovarian (n = 2), lung (n = 2), melanoma (n = 2) along with others (n = 5). Indications for percutaneous drainage were as follows: pain (36/36; 100%); fever and/or leukocytosis (34/36; 94%), and mass effect (21/36; 58%). Seven patients underwent additional sclerosis with absolute alcohol. Criteria for drainage success were temporary or definitive relief of symptoms and sepsis control. RESULTS: Successful sepsis control was achieved in all patients with sepsis (34/34; 100%) and 30/36 (83%) patients had improvement in pain. Duration of catheterization ranged from 2 to 90 days (mean = 22 days). There were four cases of fluid re-accumulation and one patient developed catheter tract seeding. Alcohol ablation was successful in two patients (2/7; 29%). Nearly all patients (34/36; 94%) died during the follow-up period. CONCLUSIONS: Percutaneous drainage was effective for palliative treatment of symptomatic cystic and necrotic tumors in the majority of patients in this series.

Non-traumatic causes of fluid in the retropharyngeal space.

There are multiple reasons for imaging the soft tissues of the neck in the emergency setting, in particular when symptoms are vague or if there is worry for complications from a certain clinical diagnosis. When fluid is seen in the retropharyngeal space, it is important to pay attention to history and look at key structures in the neck. This article will discuss anatomy of the retropharyngeal space, followed by four causes of fluid within the space that the radiologist is likely to encounter in the emergency setting: tonsillitis/pharyngitis, acute calcific tendinitis of the longus colli muscles, internal jugular vein thrombosis, and post-radiation changes. It is important to recognize these entities because each has different clinical implications and management.

Outcomes of Cataract Surgery in Patients With Exudative Age-related Macular Degeneration and Macular Fluid.

PURPOSE: To investigate whether having macular fluid on optical coherence tomography (OCT) prior to cataract surgery adversely affected vision or anatomic outcomes after cataract surgery in patients with exudative age-related macular degeneration (AMD). DESIGN: Retrospective cohort study. METHODS: We examined all patients who underwent cataract surgery and were receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections from January 1, 2012 through December 31, 2016. There were 81 eyes that underwent cataract surgery and had received at least 1 intravitreal anti-VEGF injection for a diagnosis of exudative AMD within 6 months prior to surgery. Data collected included the development of subretinal or intraretinal macular fluid, or subretinal hemorrhage, in the 6 months following surgery; number of injections; best-corrected visual acuity (BCVA); and central subfield thickness (CST). RESULTS: There was a significant improvement between preopertive and postoperative BCVA when comparing all patients (P values < .0001) and no significant difference in CST before and after surgery (P > .05). There were 23 eyes with fluid on the preoperative OCT. There were no differences in final BCVA or CST and no difference in the development of fluid postoperatively when compared to patients without fluid preoperatively (all P values > .05). These patients also saw a significant improvement in BCVA (P = .006). CONCLUSION: In a real-world setting, patients with both cataracts and wet AMD may safely undergo cataract surgery. Patients with stable preoperative fluid on OCT should be considered for cataract surgery, as these patients did well postoperatively, with no worsening of their neovascular process.

Do signs of an effusion of the temporomandibular joint on magnetic resonance imaging correlate with signs and symptoms of temporomandibular joint disease?

Effusions are common among patients with disorders of the temporomandibular joint (TMJ), but publications are limited and results inconsistent about the correlation between them and important clinical variables, in particular severity of pain and degenerative disease. We organised a retrospective study of patients who presented for the evaluation and management of arthralgia of the TMJ and myofascial pain at the University of Michigan between 2011 and 2014. Inclusion criteria were: patients who had pain that was primarily arthrogenous, and coexisting myogenous pain, who had had initial non-surgical treatment, and arthroscopy of the TMJ with or without intramuscular injection of onabotulinumtoxinA (Botox,® Allegan, Weston, Fl, USA). The primary outcome variables were pain at rest as measured by visual analogue score (VAS) and the presence of degenerative disease of the joint. The secondary outcome variables included the position of the disc and whether it was perforated, signs of synovitis, maximal interincisal opening (MIO), and duration of symptoms. We studied 47 patients (94 TMJ) who met the inclusion criteria. We found no significant differences in pain at rest before or after arthroscopy, between patients with and without effusions, or in maximal MIO or duration of symptoms between the two groups. There was, however, a significant relation between effusions and degenerative joint disease. Effusions were also associated with a lower probability of the disc being in a normal position and a higher probability of anterior disc displacement without reduction.

An exudate detection method for diagnosis risk of diabetic macular edema in retinal images using feature-based and supervised classification.

The present paper aims at presenting the methodology and first results of a detection system of risk of diabetic macular edema (DME) in fundus images. The system is based on the detection of retinal exudates (Ex), whose presence in the image is clinically used for an early diagnosis of the disease. To do so, the system applies digital image processing algorithms to the retinal image in order to obtain a set of candidate regions to be Ex, which are validated by means of feature extraction and supervised classification techniques. The diagnoses provided by the system on 1058 retinographies of 529 diabetic patients at risk of having DME show that the system can operate at a level of sensitivity comparable to that of ophthalmological specialists: it achieved 0.9000 sensitivity per patient against 0.7733, 0.9133 and 0.9000 of several specialists, where the false negatives were mild clinical cases of the disease. In addition, the level of specificity reached by the system was 0.6939, high enough to screen about 70% of the patients with no evidence of DME. These values show that the system fulfils the requirements for its possible integration into a complete diabetic retinopathy pre-screening tool for the automated management of patients within a screening programme. Graphical Abstract Diagnosis system of risk of diabetic macular edema (DME) based on exudate (Ex) detection in fundus images.

EUS-Guided Transgastric Drainage of Intraabdominal Fluid Collections.

Intraabdominal fluid collections can be a significant cause of morbi-mortality among patients with acute pancreatitis and those who underwent surgery, especially oncological ones. Nowadays, the treatment tends to be minimally invasive, so that the patient's recovery would be shorter and the quality of life higher. EUS (endoscopic ultrasound) has emerged in the last decade to fulfill that demand, alongside percutaneous and surgical drainage in the management of perigastric collections. Objectives: The main objective of this paper is to evaluate the efficacy of EUS guided drainage in terms of techincal and clinical success. Secondary objectives refer to the assessment of complete resolution of intraabdominal collection, presence of infection after drainage, overall survival. Methods: We conducted a prospective study by enrolling 31 patients who were diagnosed using EUS with perigastric intraabdominal fluid collections, from an overall of 788 EUS performed over a period of 2 years. We analyzed their evolution during 6 months after treatment, by regular examinations (ultrasound/endoscopic/computed tomography). All of them were in-patients of Bucharest Clinical Emergency Hospital, either in Endoscopy or in Surgery Departments. Data collected was processed in IBM SPSS Statistics 20. Results: Overall mean age was 51 year and intraabdominal collections average was 109 mm (range 34 250 mm) and was correlated with the method of treatment (p 0.005). Patients underwent different methods for their intraabdominal collections: EUS drainage, CT (computed-tomography)- guided percutaneous drainage, surgical intervention, alone or combined when needed. Overall mortality was 9,3% and was mainly related to the severity of the case and sepsis. Conclusions: We conclude that endoscopic ultrasound can be the first choice for drainage of intraabdominal perigastric fluid collections because it is a safe and effective technique with 100 % technical success, and with over 80 % clinical success assures a better quality of life. For collections with a diameter larger than 127 mm, we can expect however the need of combined treatment, EUS and surgery.

Endoscopic and Radiologic Findings in Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) was first described by Landis in 1978. The disease is characterized by esophageal symptoms, primarily dysphagia in adult patients, and esophageal eosinophilic infiltration. The disease is associated with characteristic endoscopic findings, including edema, rings, furrows, exudates, and strictures. The typical radiographic findings of this disorder are rings, strictures, and small-caliber esophagus. The endoscopic and radiographic findings of EoE are the topic of this review.

Idiopathic Acute Exudative Polymorphous Vitelliform Maculopathy: Clinical Spectrum and Multimodal Imaging Characteristics.

PURPOSE: To describe clinical findings in patients with acute exudative polymorphous vitelliform maculopathy (AEPVM). DESIGN: Retrospective, observational, multicenter case series review. PARTICIPANTS: Consecutive patients diagnosed with idiopathic AEPVM. METHODS: Review of clinical charts, multimodal imaging, electrophysiologic findings, and genetic findings in previously unpublished patients and review of the literature. MAIN OUTCOME MEASURES: Clinical features of idiopathic AEPVM and differential diagnosis. RESULTS: Eighteen patients (age range, 21-74 years) with typical features of AEPVM, including initial localized, serous detachments followed by the development of characteristic yellow-white deposits in the vitelliform space. Over time, this hyperautofluorescent material gravitated within the larger lesions, resulting in typical curvilinear deposits characteristic of later stages. Symptoms and clinical findings lasted from weeks to several years. Some patients showed previously undescribed features such as fluorescein-negative intraretinal cystic changes, choroidal neovascularization, serous retinal elevations mimicking retinal folds, increased choroidal thickness, lack of rapid visual recovery, and recurrence years after complete resolution of initial manifestations. CONCLUSIONS: Acute exudative polymorphous vitelliform maculopathy can present with a more variable natural course than previously described. Paraneoplastic retinopathy and autosomal recessive bestrophinopathy closely resemble AEPVM, necessitating medical and hereditary evaluation to exclude these clinical possibilities. This series of patients with AEPVM expands the clinical spectrum of the disorder, including demographics, clinical manifestations, imaging features, natural course, and visual prognosis.