Expert-Level Detection of Referable Glaucoma from Fundus Photographs in a Safety Net Population: The AI and Teleophthalmology in Los Angeles Initiative.

Purpose: To develop and test a deep learning (DL) algorithm for detecting referable glaucoma in the Los Angeles County (LAC) Department of Health Services (DHS) teleretinal screening program. Methods: Fundus photographs and patient-level labels of referable glaucoma (defined as cup-to-disc ratio [CDR] ≥ 0.6) provided by 21 trained optometrist graders were obtained from the LAC DHS teleretinal screening program. A DL algorithm based on the VGG-19 architecture was trained using patient-level labels generalized to images from both eyes. Area under the receiver operating curve (AUC), sensitivity, and specificity were calculated to assess algorithm performance using an independent test set that was also graded by 13 clinicians with one to 15 years of experience. Algorithm performance was tested using reference labels provided by either LAC DHS optometrists or an expert panel of 3 glaucoma specialists. Results: 12,098 images from 5,616 patients (2,086 referable glaucoma, 3,530 non-glaucoma) were used to train the DL algorithm. In this dataset, mean age was 56.8 ± 10.5 years with 54.8% females and 68.2% Latinos, 8.9% Blacks, 2.7% Caucasians, and 6.0% Asians. 1,000 images from 500 patients (250 referable glaucoma, 250 non-glaucoma) with similar demographics (p ≥ 0.57) were used to test the DL algorithm. Algorithm performance matched or exceeded that of all independent clinician graders in detecting patient-level referable glaucoma based on LAC DHS optometrist (AUC = 0.92) or expert panel (AUC = 0.93) reference labels. Clinician grader sensitivity (range: 0.33-0.99) and specificity (range: 0.68-0.98) ranged widely and did not correlate with years of experience (p ≥ 0.49). Algorithm performance (AUC = 0.93) also matched or exceeded the sensitivity (range: 0.78-1.00) and specificity (range: 0.32-0.87) of 6 LAC DHS optometrists in the subsets of the test dataset they graded based on expert panel reference labels. Conclusions: A DL algorithm for detecting referable glaucoma developed using patient-level data provided by trained LAC DHS optometrists approximates or exceeds performance by ophthalmologists and optometrists, who exhibit variable sensitivity and specificity unrelated to experience level. Implementation of this algorithm in screening workflows could help reallocate eye care resources and provide more reproducible and timely glaucoma care.

Phthisical eye and orbital ischemia after cosmetic platelet-rich plasma injection to the forehead.

Purpose: To report a case of retrograde embolism of cosmetic injection of platelet-rich plasma (PRP) to the ophthalmic artery, resulting in orbital ischemia, blindness, and eventual phthisis bulbi. Observations: A 37-year-old woman presented with two days of vision loss OS beginning seconds after undergoing cosmetic PRP filler injections to the face at an outside clinic. Immediately after injection to the left medial forehead, the patient reported bleeding, transient loss of consciousness, and complete vision loss OS. Two days later, vision remained no light perception OS and she exhibited manifestations of both anterior and posterior segment ischemia in the left eye. These findings were ultimately attributed to retrograde embolism to the ophthalmic artery via inadvertent injection of PRP into the supratrochlear or supraorbital arteries. She ultimately did not regain her vision in the left eye and the eye became enophthalmic and phthisical. Conclusions: After conducting a literature review on August 18, 2023, utilizing PubMed and Google Scholar, and searching for the key words "platelet-rich plasma" and "vision loss" or "vision impairment," we did not find any prior reports of anterior segment ischemia or pan-orbital ischemia resulting in phthisis bulbi. In the setting of vision changes after cosmetic platelet-rich plasma filler injection. Additionally, there is no validated therapy for ophthalmic artery occlusion from any cosmetic filler embolism. Further research should prioritize developing therapeutic guidelines for managing such complications. Injectors should also be educated to emergently refer patients to hospitals with ophthalmology consults available and stroke protocols in place.

SARS-CoV-2 Parainfectious Optic Neuropathy: 3 Case Reports and a Review of the Literature.

BACKGROUND: Parainfectious optic neuritis is an inflammatory reaction that occurs shortly after an infection without direct invasion by a pathogen. The clinical profile depends on the infectious organism. Cases of SARS-CoV-2 parainfectious optic neuritis have been reported in the literature, but there are no reviews that have applied strict inclusion criteria to more definitively establish the clinical profile associated with SARS-CoV-2. METHODS: We present 3 new cases of SARS-CoV-2 parainfectious optic neuritis. We also review the literature for definite cases by selecting only those with unambiguous clinical features and MRI findings of optic neuritis, positive SARS-CoV-2 polymerase chain reaction or serology, and the absence of myelin oligodendrocyte-glycoprotein or aquaporin-4 antibodies or other diseases associated with optic neuritis. RESULTS: We report 2 cases of monophasic, unilateral SARS-CoV-2 parainfectious optic neuritis with optic disc edema and nadir visual acuities of finger counting. We report 1 case of mild SARS-CoV-2 parainfectious optic neuritis that featured cotton wool spots, peripapillary wrinkles and hemorrhages, and recurrence after an initial steroid taper. We identified 6 cases of unambiguous SARS-CoV-2 parainfectious optic neuritis from the literature. Combining our case series with the case reports in the literature, the average age was 42.8 years, 3/9 had bilateral disease, 6/8 had optic disc edema, 8/9 had nadir visual acuity of finger counting or worse, and all recovered visual acuity to 20/40 or better after therapy with steroids. CONCLUSIONS: SARS-CoV-2 parainfectious optic neuritis has a clinical profile that is atypical for idiopathic optic neuritis but fairly typical of parainfectious forms of optic neuritis with a severely reduced nadir visual acuity, high likelihood of bilaterality, high incidence of optic disc edema, and prompt and significant response to corticosteroids. Further study with long-term follow-up and epidemiologic investigation will be needed to further characterize this clinical entity.

Diversity in Academic Ophthalmology: Disparities and Opportunities from Medical School to Practice.

INTRODUCTION: Compared to the United States population as a whole, physicians are more likely to identify as men, identify as Asian or non-hispanic White, and be raised in wealthier households. Racial, ethnic, gender, and socioeconomic representation in ophthalmology is often blamed on the pipeline of matriculants. METHODS: This review collects recent data from the US census, AAMC, and primary literature on gender, racial, ethnic, and socioeconomic diversity from medical school to ophthalmology practice. RESULTS: Data from the medical and ophthalmology literature shows that medical students are less diverse than medical school applicants, ophthalmology residencies are less diverse than graduating medical students, and ophthalmology departments are less diverse than those of most other specialties. DISCUSSION: At each level, there are limitations in representation beyond the pipeline of medical school applicants or medical students applying to ophthalmology. There are many practical steps the field can take at each level of training to move the specialty toward more equitable representation.

Neurologic Manifestations of the World Health Organization's List of Pandemic and Epidemic Diseases.

The World Health Organization (WHO) monitors the spread of diseases globally and maintains a list of diseases with epidemic or pandemic potential. Currently listed diseases include Chikungunya, cholera, Crimean-Congo hemorrhagic fever, Ebola virus disease, Hendra virus infection, influenza, Lassa fever, Marburg virus disease, Neisseria meningitis, MERS-CoV, monkeypox, Nipah virus infection, novel coronavirus (COVID-19), plague, Rift Valley fever, SARS, smallpox, tularemia, yellow fever, and Zika virus disease. The associated pathogens are increasingly important on the global stage. The majority of these diseases have neurological manifestations. Those with less frequent neurological manifestations may also have important consequences. This is highlighted now in particular through the ongoing COVID-19 pandemic and reinforces that pathogens with the potential to spread rapidly and widely, in spite of concerted global efforts, may affect the nervous system. We searched the scientific literature, dating from 1934 to August 2020, to compile data on the cause, epidemiology, clinical presentation, neuroimaging features, and treatment of each of the diseases of epidemic or pandemic potential as viewed through a neurologist's lens. We included articles with an abstract or full text in English in this topical and scoping review. Diseases with epidemic and pandemic potential can be spread directly from human to human, animal to human, via mosquitoes or other insects, or via environmental contamination. Manifestations include central neurologic conditions (meningitis, encephalitis, intraparenchymal hemorrhage, seizures), peripheral and cranial nerve syndromes (sensory neuropathy, sensorineural hearing loss, ophthalmoplegia), post-infectious syndromes (acute inflammatory polyneuropathy), and congenital syndromes (fetal microcephaly), among others. Some diseases have not been well-characterized from a neurological standpoint, but all have at least scattered case reports of neurological features. Some of the diseases have curative treatments available while in other cases, supportive care remains the only management option. Regardless of the pathogen, prompt, and aggressive measures to control the spread of these agents are the most important factors in lowering the overall morbidity and mortality they can cause.

Infectious ocular motor neuropathies.

PURPOSE OF REVIEW: Describe the range of infectious causes of ocular motor neuropathies, from common presentations to unusual manifestations of diseases less frequently seen in the developed world. Provide information on recent developments in diagnostic testing for pathogens that may cause ocular motor neuropathies. RECENT FINDINGS: Antigen detection in serum or CSF has improved the diagnosis of cryptococcal disease. Cartridge PCR testing for tuberculosis has increased diagnostic accuracy, though tuberculous meningitis remains difficult to diagnose. Rapid, multiplex PCR and unbiased sequencing allow for diagnosis of a wider range of organisms. SUMMARY: Infectious ocular motor neuropathies can occur anywhere along the length of cranial nerves III, IV, and VI. Characteristic clinical findings and imaging can be used to localize infections. Infectious causes may have characteristic clinical, laboratory, or imaging findings, but must still be carefully separated from inflammatory or neoplastic conditions.

Enhanced Detection of Edema in Malignant Anterior Circulation Stroke (EDEMA) Score: A Risk Prediction Tool.

BACKGROUND AND PURPOSE: Rapid recognition of those at high risk for malignant edema after stroke would facilitate triage for monitoring and potential surgery. Admission data may be insufficient for accurate triage decisions. We developed a risk prediction score using clinical and radiographic variables within 24 hours of ictus to better predict potentially lethal malignant edema. METHODS: Patients admitted with diagnosis codes of cerebral edema and ischemic stroke, NIHSS score (National Institute of Health Stroke Score) of ≥8 and head computed tomographies within 24 hours of stroke onset were included. Primary outcome of potentially lethal malignant edema was defined as death with midline shift ≥5 mm or decompressive hemicraniectomy. We performed multivariate analyses on data available within 24 hours of ictus. Bootstrapping was used to internally validate the model, and a risk score was constructed from the results. RESULTS: Thirty-three percent of 222 patients developed potentially lethal malignant edema. The final model C statistic was 0.76 (confidence interval, 0.68-0.82) in the derivation cohort and 0.75 (confidence interval, 0.72-0.77) in the bootstrapping validation sample. The EDEMA score (Enhanced Detection of Edema in Malignant Anterior Circulation Stroke) was developed using the following independent predictors: basal cistern effacement (=3); glucose ≥150 (=2); no tPA (tissue-type plasminogen activator) or thrombectomy (=1), midline shift >0 to 3 (=1), 3 to 6 (=2), and 6 to 9 (=4); >9 (=7); and no previous stroke (=1). A score over 7 was associated with 93% positive predictive value. CONCLUSIONS: The EDEMA score identifies patients at high risk for potentially lethal malignant edema. Although it requires external validation, this scale could help expedite triage decisions in this patient population.

Student-directed retrieval practice is a predictor of medical licensing examination performance.

INTRODUCTION: A large body of evidence indicates that retrieval practice (test-enhanced learning) and spaced repetition increase long-term information retention. Implementation of these strategies in medical curricula is unfortunately limited. However, students may choose to apply them autonomously when preparing for high-stakes, cumulative assessments, such as the United States Medical Licensing Examination Step 1. We examined the prevalence of specific self-directed methods of testing, with or without spaced repetition, among preclinical students and assessed the relationship between these methods and licensing examination performance. METHODS: Seventy-two medical students at one institution completed a survey concerning their use of user-generated (Anki) or commercially-available (Firecracker) flashcards intended for spaced repetition and of boards-style multiple-choice questions (MCQs). Other information collected included Step 1 score, past academic performance (Medical College Admission Test [MCAT] score, preclinical grades), and psychological factors that may have affected exam preparation or performance (feelings of depression, burnout, and test anxiety). RESULTS: All students reported using practice MCQs (mean 3870, SD 1472). Anki and Firecracker users comprised 31 and 49 % of respondents, respectively. In a multivariate regression model, significant independent predictors of Step 1 score included MCQs completed (unstandardized beta coefficient [B] = 2.2 × 10- 3, p < 0.001), unique Anki flashcards seen (B = 5.9 × 10- 4, p = 0.024), second-year honours (B = 1.198, p = 0.002), and MCAT score (B = 1.078, p = 0.003). Test anxiety was a significant negative predictor (B= - 1.986, p < 0.001). Unique Firecracker flashcards seen did not predict Step 1 score. Each additional 445 boards-style practice questions or 1700 unique Anki flashcards was associated with an additional point on Step 1 when controlling for other academic and psychological factors. CONCLUSIONS: Medical students engage extensively in self-initiated retrieval practice, often with spaced repetition. These practices are associated with superior performance on a medical licensing examination and should be considered for formal support by educators.

Pore size and pore shape--but not mesh density--alter the mechanical strength of tissue ingrowth and host tissue response to synthetic mesh materials in a porcine model of ventral hernia repair.

BACKGROUND: Over 100 types of soft tissue repair materials are commercially available for hernia repair applications. These materials vary in characteristics such as mesh density, pore size, and pore shape. It is difficult to determine the impact of a single variable of interest due to other compounding variables in a particular design. Thus, the current study utilized prototype meshes designed to evaluate each of these mesh parameters individually. METHODS: Five prototype meshes composed of planar, monofilament polyethylene terephthalate (PET) were evaluated in this study. The meshes were designed to focus on three key parameters, namely mesh density, pore size, and pore shape. The prototype meshes were implanted in the preperitoneal, retrorectus space in a porcine model of ventral incisional hernia repair, and tissue ingrowth characteristics were evaluated after 90 days. Mesh-tissue composite specimens were obtained from each repair site and evaluated via T-peel mechanical testing. Force-displacement data for each T-peel test were analyzed and five characteristics of tissue ingrowth reported: peak force (fp), critical force (fc), fracture energy (Γc), work (W), and work density (Wden). Hematoxylin and eosin (H&E) stained sections of explanted mesh-tissue composites were also assessed for characteristics of tissue response including cellular infiltration, cell types, inflammatory response, extracellular matrix deposition, neovascularization, and fibrosis, with a composite score assigned to represent overall tissue response. RESULTS: The medium-weight, very large pore, hexagonal (MWVLH) mesh performed significantly better than the light-weight, medium pore, diamond (LWMD) mesh for all parameters evaluated (fp, fc, Γc, W, Wden) and trended toward better results than the medium-weight, medium pore, diamond (MWMD) mesh for the majority of the parameters evaluated. When the data for the five meshes was grouped to evaluate mesh density, pore size, and pore shape, differences were more pronounced. No significant differences were observed with respect to mesh density, however significant improvement in mechanical strength of tissue ingrowth occurred as pore size increased from medium to very large. In addition, the hexagonal pores resulted in the strongest tissue ingrowth, followed by the square pores, and finally the diamond pores. Scores for several histological parameters were significantly different for these prototype meshes. For example, the MWVLH mesh showed significantly greater tissue ingrowth by neovascularization histological score than MWMD and MWVLS meshes (p<0.05) and significantly less fibrosis than LWMD and MWVLS meshes (p<0.05). CONCLUSION: Pore shape and pore size significantly altered the mechanical strength of tissue ingrowth and host-site integration in a porcine model of ventral hernia repair, while mesh density had no effect.