A new computer-aided diagnosis tool based on deep learning methods for automatic detection of retinal disorders from OCT images.

PURPOSE: Early detection of retinal disorders using optical coherence tomography (OCT) images can prevent vision loss. Since manual screening can be time-consuming, tedious, and fallible, we present a reliable computer-aided diagnosis (CAD) software based on deep learning. Also, we made efforts to increase the interpretability of the deep learning methods, overcome their vague and black box nature, and also understand their behavior in the diagnosis. METHODS: We propose a novel method to improve the interpretability of the used deep neural network by embedding the rich semantic information of abnormal areas based on the ophthalmologists' interpretations and medical descriptions in the OCT images. Finally, we trained the classification network on a small subset of the online publicly available University of California San Diego (UCSD) dataset with an overall of 29,800 OCT images. RESULTS: The experimental results on the 1000 test OCT images show that the proposed method achieves the overall precision, accuracy, sensitivity, and f1-score of 97.6%, 97.6%, 97.6%, and 97.59%, respectively. Also, the heat map images provide a clear region of interest which indicates that the interpretability of the proposed method is increased dramatically. CONCLUSION: The proposed software can help ophthalmologists in providing a second opinion to make a decision, and primitive automated diagnoses of retinal diseases and even it can be used as a screening tool, in eye clinics. Also, the improvement of the interpretability of the proposed method causes to increase in the model generalization, and therefore, it will work properly on a wide range of other OCT datasets.

Suprachoroidal injection of triamcinolone acetonide plus intravitreal bevacizumab in diabetic macular edema: a randomized pilot trial.

BACKGROUND: To investigate the efficacy of injecting suprachoroidal triamcinolone acetonide (SCTA) plus intravitreal bevacizumab (IVB) into patients with center-involving diabetic macular edema (CI-DME). METHODS: In this phase 2/3 randomized controlled pilot trial, sixty-six eyes with CI-DME and best-corrected visual acuity (BCVA) of at most 20/50 Snellen chart were randomly assigned into two groups. Monotherapy arm received sham injection plus 3 monthly IVB doses and combination arm received a single dose of SCTA and 3 monthly IVB doses. The mean improvements in BCVA and Central subfield thickness (CST), over the three-month was considered the main efficacy outcomes. RESULTS: The mean BCVA improvements were obtained respectively as - 0.20 ± 0.20 log [minimum angle of resolution (MAR)] (P = 0.004) and 0.37 ± 0.24 log MAR (P < 0.001) in monotherapy and combination arms [between-group analysis (P = 0.014)]. Significant improvements were also observed in CST (P = 0.019) in the combination arm compared to the other. No adverse events (elevated intraocular pressure, cataract) were observed in any of the study arms. CONCLUSION: Significant improvements in BCVA and retinal anatomical outcomes demonstrated the additive effects of SCTA to those of anti-vascular endothelial growth factors with no short-term side effects and this combination appears to be a promising option in the management of patients with CI-DME. TRIAL REGISTRATION: The trial was registered in Iranian Registry of Clinical Trials (IRCT20200314046761N1).

Diabetic retinopathy and corneal endothelial parameters: an analytical cross-sectional study.

BACKGROUND: To investigate the possible association of different pattern of diabetic retinopathy (DR) on corneal endothelium cells in type 2 diabetes mellitus patients. METHODS: In this descriptive-analytical cross-sectional study, corneal endothelium parameters including endothelial cell density (ECD), average cell size (AVG), coefficient of variation in cell size (CV), and hexagonality (Hex) were evaluated by non-contact specular microscopy. RESULTS: One hundred and thirty-four eyes of 134 diabetic patients including 77 females (57.5%) with a mean age of 61.03 ± 8.08 years were enrolled. The overall corneal parameters in diabetic patients with and without retinopathy were not significantly different (P > 0.05). There is a significant relationship between CV and the duration of the disease with age variable control (B = 0.369, p-value < 0.001). CONCLUSIONS: Corneal endothelial parameters were not associated with DM in patients without and with DR. There is a significant relationship between CV and the duration of the disease with age variable control.

Dorzolamide nanoliposome as a long action ophthalmic delivery system in open angle glaucoma and ocular hypertension patients.

IMPORTANCE: To reduce the frequency of dorzolamide eye drop administration and increasing the duration of action. BACKGROUND: This study aims to compare the effect of dorzolamide loaded-nanoliposome with marketed dorzolamide HCl eye drop on intraocular pressure in primary open angle glaucoma and ocular hypertension patients. DESIGN: A randomized study was conducted in a hospital. PARTICIPANTS: Twenty patients with primary open angle glaucoma or ocular hypertension (in both eyes) diagnosis were recruited as participants. METHODS: Dorzolamide loaded-nanoliposome was prepared by thin layer hydration method and characterized. Intra ocular pressure were compared between the two groups who received marketed dorzolamide solution or dorzolamide-loaded nanoliposome. MAIN OUTCOME MEASURES: The main outcome measures include intraocular pressure initially (day 0) and on days 14 and 28 and adverse effect of dorzolamide-loaded nanoliposome eye drop. RESULTS: Based on the results of repeated measure, intra ocular pressure was seen to decrease in both the groups. But these reductions in the intervention group (dorzolamide-loaded eye drop) were significantly higher than those in control group (p < 0.05). CONCLUSION: This study confirmed safety and long-lasting efficacy of dorzolamide loaded-nanoliposome eye drop. The highly enhanced permeation through the cornea can be attributed to similarity of phospholipid bilayer of liposomes to the biological membrane and their small particle size and positive zeta potential.

Intraocular Pressure and Corneal Biomechanical Changes after Water-Drinking Test in Glaucoma Patients.

PURPOSE: To evaluate intraocular pressure (IOP) and corneal biomechanical changes after water-drinking test (WDT) in glaucomatous and normal eyes using Ocular Response Analyzer (ORA). METHODS: This prospective study included 30 medically controlled, 30 surgically treated glaucoma patients and 30 normal individuals. Baseline measurements included central corneal thickness (CCT), ORA-derived corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated IOP (IOPcc), and Goldmann-correlated IOP (IOPg). Measurements were repeated 15, 30, and 60 min after drinking 1000 mL of water. Changes in ORA parameters were compared among the groups. RESULTS: All groups showed a significant increase in IOPg and IOPcc at all test points. Peak IOP occurred at 15 min and decreased gradually over time but did not reach the baseline values at 60 min. The surgery group had significantly lower baseline IOPg and IOPcc (10.7 ± 3.1 and 12.8 ± 3.7 mmHg, P = 0.001 and 0.01), lower peak IOPg and IOPcc (14.4 ± 4.6 and 16.2 ± 4.6 mmHg, P = 0.003 and 0.034), and lower percent IOPg and IOPcc fluctuations (13 ± 5.6 and 15 ± 5.9, P = 0.0001 and 0.002), respectively, compared to the medical group. Baseline CH and its fluctuations were not significantly different among the groups. CH decreased to a trough corresponding to peak IOPcc. There was a significant negative correlation between IOPcc and CH (r = -0.609, P < 0.001). The medical group showed more CRF fluctuations compared to normal group.(P = 0.039). CONCLUSION: Surgically treated glaucomatous eyes show less IOP fluctuations and lower peak IOP after WDT compared to medically controlled and normal eyes.

Effect of capsular tension ring implantation on predicted refractive error after cataract surgery in patients with pseudoexfoliation syndrome.

AIM: To investigate the effect of capsular tension ring (CTR) implantation on predicted refractive error after cataract surgery in patients with pseudoexfoliation (PEX) syndrome. METHODS: This double-blind randomized clinical trial was conducted on 60 patients with PEX syndrome referring to Imam Khomeini Hospital affiliated to Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran, for undergoing cataract surgery. The study population was divided into two groups, namely CTR group (n=30) and non-CTR group (control group; n=30). The refractive error and anterior chamber depth (ACD) were measured 1wk, 1mo, and 3mo after phacoemulsification (PE) surgery. RESULTS: The results indicated no statistically significant difference between the two groups in terms of predicted refractive error (obtained by subtracting preoperative predicted refractive error from actual postoperative refractive error) 1wk (P=0.47), 1mo (P=0.30), and 3mo (P=0.06) after the PE surgery. Regarding the CTR group, the changes of ACD was statistically significant 1 and 3mo after the PE surgery, compared to those obtained 1wk post-surgery (P=0.005). CONCLUSION: The CTR implantation in PEX cataractous patients without zonulysis has no statistically significant effect on the predicted refraction and ACD changes after PE. The predicted refraction error has a hyperopic shift in both groups. The results reveal the unnecessary of calculating modified IOL in CTR implantation.

Serum Vitamin A Levels in Patients with Chalazion.

Chalazion is a chronic, localized lipogranulomatous inflammation of the sebaceous glands of the lids. Chalazion occurs often secondary to blockage of the sebaceous gland ducts. Some studies have reported vitamin A deficiency as a risk factor for chalazion. In this study, we determined the serum levels of vitamin A in patients with chalazion. The study involved a total of 107 subjects (52 patients with chalazion and 55 control healthy subjects). The study was conducted at the Ophthalmology Clinics of Imam Khomeini Hospital, Ahwaz Jundishapur University of Medical Sciences, Ahwaz, Iran between September 2014 and February 2015. The subjects were divided into three groups according to age: 7-12 years old, 13-19 years old, and more than 19 years old. Patients were further divided into four subgroups based on the type of chalazion: single, multiple, primary, and recurrent. Blood samples were collected and the serum was tested for levels of vitamin A using high-performance liquid chromatography (HPLC). The average serum vitamin A levels in patients with chalazion in the age groups of 7-12 and 13-19 years were significantly lower than in their control counterparts. Serum vitamin A levels in patients with recurrent, multiple chalazia were significantly lower than in patients with primary, multiple chalazia (P = 0.026) and patients with a recurrent, single chalazion (P = 0.029). In conclusion, chalazion could be one of the ocular presentations of vitamin A deficiency.

Race by Gender Group Differences in the Protective Effects of Socioeconomic Factors Against Sustained Health Problems Across Five Domains.

BACKGROUND: Despite the existing literature on the central role of socioeconomic status (SES; education and income) for maintaining health, less is known about group differences in this effect. Built on the intersectionality approach, this study compared race by gender groups for the effects of baseline education and income on sustained health problems in five domains: depressive symptoms, insomnia, physical inactivity, body mass index (BMI), and self-rated health (SRH). METHODS: Data came from waves 7, 8, and 10 of the Health and Retirement Study (HRS), which were collected in 2004, 2006, and 2010, respectively. The study followed 37,495 white and black men and women above age 50 for up to 6 years. This number included 12,495 white men, 15,581 white women, 3839 black men, and 5580 black women. Individuals reported their depressive symptoms (Center for Epidemiological Studies-Depression (CES-D) 11), insomnia, physical inactivity, BMI, and SRH across all waves. Multigroup structural equation modeling (SEM) was used to compare black men, black women, white men, and white women for the effects of education and income in 2004 on sustained health problems from 2004 to 2010. RESULTS: In the pooled sample, higher education and income at baseline were associated with lower sustained health problems across all five domains. However, race by gender group differences were found in the effects of education and income on sustained insomnia, physical inactivity, and BMI, but not depressive symptoms and SRH. The protective effects of education against insomnia, physical inactivity, and BMI were not found for black men. For black women, the effect of education on BMI was not found. Income had a protective effect against sustained high BMI among white and black women but not white and black men. CONCLUSION: The intersection of race and gender alters the protective effects of social determinants on sustained health problems such as insomnia, physical inactivity, and BMI. Social groups particularly vary in the operant mechanisms by which SES contributes to maintaining health over time. The health effects are less universal for education than income. Race by gender groups differ more in SES determinants of BMI, insomnia, and physical inactivity than depressive symptoms and SRH.

Baseline Religion Involvement Predicts Subsequent Salivary Cortisol Levels Among Male But not Female Black Youth.

BACKGROUND: Compared to Whites, Blacks are exposed to higher levels of chronic stress in the United States. As a result, major Black-White differences exist in the baseline and response of cortisol. Yet, the potential association between baseline religiosity and subsequent cortisol levels of Blacks are not known. OBJECTIVES: In the current study we aimed to determine the association between baseline religious behaviors and daytime salivary cortisol level among male and female Black youth. MATERIALS AND METHODS: With a longitudinal design, data came from wave 1 (1994) and wave 6 (2000) of a cohort from an urban area in the Midwest of the United States. The study followed 227 Black adolescents (109 males and 118 females) for six years. Socio-demographics and religious behaviors (frequency of participation in religious activities) were measured at baseline. Base morning cortisol level at wave 6 was the outcome. We fitted a linear regression model to test the association between baseline religiosity at wave 1 and cortisol level at wave 6, while baseline age, socio-economics, and psychological symptoms were controlled. RESULTS: In the pooled sample, frequency of participation in religious activities at baseline was negatively associated with mean cortisol level at follow up (r = -0.29, P > 0.01) among all, males (r = -0.38, P > 0.01), but not females (r = -.20, P > 0.05). Frequency of participation in religious activities remained a significant predictor of subsequent cortisol level (b = -0.283, 95% CI = -.107 - -0.022) while the effect of age, socioeconomics, and psychological symptoms were controlled. We could only find such an association among male Black youth (b = -0.368, 95% CI = -0.148 - -0.024) but not female Black youth (b = -0.229, 95% CI = -.113 - 0.011). CONCLUSIONS: Religiosity has been used as a coping mechanism among Blacks. Religiosity may also be related to stress regulation among Black youth. Future studies need to test complex associations between race, sex, religiosity, chronic stress, coping, and function of hypothalamo-pituitary-adrenal (HPA). It is not known whether male Black youth who are and those who are not religious differently cope with stress associated with daily discrimination and living in disadvantaged neighborhoods.

Modified Descemet's Stripping Automated Endothelial Keratoplasty for Congenital Hereditary Endothelial Dystrophy.

A 19-year-old male with congenital hereditary endothelial dystrophy (CHED) presented with severe bilateral corneal clouding precluding any view of the intraocular structures. He underwent modified Descemet's stripping automated endothelial keratoplasty (DSAEK) technique including a suture pull-through technique to prevent lens damage. Surgery resulted in progressive clearing of the cornea and decreased corneal thickness. Visual acuity increased from hand motions preoperatively to counting fingers at 4 m after 4 months. DSAEK can be successfully performed in phakic eyes with CHED as an alternative to penetrating keratoplasty. It has the advantage of less wound problems and better preservation of globe integrity especially in children.

Comparison of IOPen rebound tonometer with Goldmann applanation tonometer at different IOP levels.

AIM: To compare the accuracy of IOPen rebound tonometer with Goldmann applanation tonometer (GAT) in individuals with low, normal and high intraocular pressure (IOP) and to evaluate the effect of central corneal thickness (CCT) on IOP measurements. METHODS: This cross-sectional study consisted of 159 participants. IOP of one eye of each subject was measured consecutively with IOPen and GAT. Then CCT was measured using an ultrasonic pachymeter. Based on GAT IOP readings, participants were divided into low, normal and high IOP groups. Correlation between tonometers and CCT was calculated by spearman's correlation coefficient. Agreement between tonometers was evaluated using Bland-Altman method. RESULTS: Non-significant underestimation of IOP by IOPen was observed in low IOP group (Mean difference: 0.20mmHg; P=0.454) and also in normal IOP group (Mean difference: 0.56mmHg; P=0.065). However, IOPen significantly overestimated IOP in high IOP group (Mean difference: 1.06mmHg; P=0.038). The 95% limits of agreement (LoA) width between IOPen and GAT IOPs were 7.84, 8.57 and 14.27mmHg in low, normal and high IOP groups, respectively. Low IOP group had thinner corneas compared to high IOP group (P=0.034). IOP measurements taken by IOPen were not influenced by CCT (P=0.099) while poor correlation between CCT and GAT was found (R=0.17, P=0.032). Using receiver operating characteristic (ROC) curve, cutoff value of 18.75mmHg was determined for IOPen with sensitivity of 98.1 and specificity of 97.2%. CONCLUSION: Accuracy of IOPen is comparable to GAT in patients with low or normal IOP but IOPen overestimates IOP at high IOP levels. CCT does not affect IOP readings with IOPen.

Normobaric oxygen therapy for scleral ischemia or melt.

PURPOSE: To investigate the efficacy of normobaric oxygen (NBO) therapy for treatment of scleral ischemia or melt. METHODS: This prospective interventional case series includes 9 eyes of 8 patients with scleral ischemia or melt of diverse etiologies. Following the failure of conventional medical and/or surgical therapy to improve ischemia or upon clinical deterioration, NBO was initiated. All patients received 100% NBO at flow rate of 10 liters/minute by face mask for 1 hour, twice daily until complete vascularization of ischemic areas. Main outcome measures were improvement of scleral ischemia and healing of conjunctival epithelial defects. RESULTS: NBO therapy led to epithelialization and vascularization of the ischemic sclera in all eyes; the repair process began 3-4 days after NBO had been initiated and was completed in 18.1±4.7 (range, 10-25) days. All patients remained stable over a 9-month follow-up period. CONCLUSION: NBO therapy seems effective for treatment of scleral ischemia or melt, and hence can be considered as a non-invasive alternative to surgical intervention in these conditions.

Histologic evaluation of normobaric oxygen therapy safety in an animal model.

BACKGROUND: Oxygen therapy, as a therapeutic modality, can be used for long periods of times. However, it may be accompanied by potential complications and side effects. OBJECTIVES: To evaluate the side effects of normobaric oxygen therapy in rabbits. MATERIALS AND METHODS: In a double-blind experiment, 28 white New Zealand rabbits were randomized into an oxygen treatment group (n = 14) and a control group (n = 14). The oxygen treatment group received 100% oxygen at a flow rate of 5 L/min for 1 h daily, for 1 month. The animals were euthanized at the end of the study, and following autopsy a histological evaluation was carried out to detect levels of oxygen toxicity in their; lungs, liver, brain, heart, kidney, eyes and spleen. RESULTS: Histological evaluation revealed no evidence of toxicity in the examined tissues, compared with the control group. CONCLUSIONS: Oxygen therapy at a flow rate of 5 L/min for 1 h daily for 1 month had no systemic toxicity and it appears to be safe in rabbits.

Can a trial of motivational lifestyle counseling be effective for controlling childhood obesity and the associated cardiometabolic risk factors?

OBJECTIVES: This study was conducted to assess the effectiveness of a simple office-based program for encouraging healthy lifestyle on controlling childhood obesity and associated cardiometabolic risk factors. METHODS: This non-randomized 24-week lifestyle modification trial was conducted among 457 obese children and adolescents, aged 2-18 years, who had at least one cardiometabolic risk factor in addition to obesity. This trial included three components of exercise, diet education and behavior modification, with all recommendations provided by a pediatrician, two general physicians and a nurse. Instead of strict inhibitory recommendations, healthier lifestyle was encouraged. RESULTS: Overall 448 (98.04%) of enrolled children completed the trial with a mean age of 9.6 ± 2.9 years. After the trial, the mean of anthropometric measures and cardiometabolic risk factors decreased significantly, the mean high-density lipoprotein cholesterol (HDL-C) increased significantly, and the prevalence of the metabolic syndrome decreased from 20.8% to 1.8%. Triglycerides, LDL-C, diastolic blood pressure and WC had the highest decrease in all age groups, with the most prominent changes in the 14-18-year age group. By each -1SD decline in BMI and WC, risk factors had significant improvement. CONCLUSION: Motivational office-based counseling can be effective in treatment of childhood obesity and its associated cardio-metabolic risk factors. Such approach can be implemented in the primary health care system; and can be of special concern in low- and middle-income countries with limited human and financial resources. We suggest that expanding the roles of non-physician clinicians such as nurse practitioners can help to increase the amount of time available for such services.

Iranian research output in pediatrics: 1975-2007.

BACKGROUND: By providing a picture from published articles in a field, bibliometric studies can inform policy-makers in their challenging research funding decisions. In this regard, we applied bibliometric analysis to the Iranian pediatrics articles published in PubMed indexed journals between 1975 and 2007. METHODS: We evaluated all pediatric articles that had been published from Iran in different PubMed indexed journals from 1975 to 2007. Journal data (i.e. date of publishing, journal name, impact factor of the journal, language), authors data (i.e. number of authors, international collaboration, affiliation of the corresponding author), and paper characteristics [i.e. type of article, research design, study population (neonate, infant, child, and adolescent), and specialty] were registered. RESULTS: During this period of time, 819 articles from Iran had been published in PubMed indexed journals, with a sharp increasing trend after 2002. Impact factors were up to 25.8. Paper had an international co-author in 13.7%. Regarding study population, 24.1% of studies were published on neonates, 23.6% on infants, and the remaining 66.3% of studies were performed on children and adolescents from 2 to 18 years old. Infectious disease was the most frequent area of research, followed by public health and metabolic disease. Original articles were the most frequent type (89.7%) of the published articles. Study design was cross-sectional in 51.2%, retrospective in 36.3%, and prospective in 11.6%. Clinical trials made up 4.8% of the total papers. CONCLUSIONS: Contribution of Iran in production of pediatrics science is showing a sharp increase after 2002, this pattern is in parallel with other research fields.

Importance of socioeconomic, clinical, and psychological factors on health-related quality of life in adolescents after kidney transplant.

OBJECTIVES: Health-related quality of life after kidney transplant in adolescents is a major concern; nevertheless, there is a paucity of data on the variables that have an effect on it. This study evaluated the extent to which socioeconomic, clinical, and psychological characteristics explain the variance in the health-related quality of life of adolescent Iranian kidney transplant recipients. MATERIALS AND METHODS: Into a hierarchical regression analysis, the cross-sectional socioeconomic, clinical, and psychological characteristics were entered among 55 adolescent Iranian kidney transplant recipients. RESULTS: The relative predictive power of socioeconomic, clinical, and psychological variables with respect to health-related quality of life was 21.8% (P = .088), 21.2% (P = .014), and 27.6% (P = .001). CONCLUSIONS: Psychological factors had a greater relative predictive power in postrenal transplant health-related quality of life of adolescents than did socioeconomic and clinical characteristics. Further research should target improvement of health-related quality of life in adolescent kidney recipients by psychological intervention.