Use of Diagnostic Codes for Primary Open-Angle Glaucoma Polygenic Risk Score Construction in Electronic Health Record-linked Biobanks.

PURPOSE: Polygenic risk scores (PRSs) likely predict risk and prognosis of glaucoma. We compared the PRS performance for primary open-angle glaucoma (POAG), defined using International Classification of Diseases (ICD) codes versus manual medical record review. DESIGN: Retrospective cohort study METHODS: We identified POAG cases in Mount Sinai BioMe and Mass General Brigham (MGB) biobank using ICD codes. We confirmed POAG based on optical coherence tomograms and visual fields. In a separate 5% sample, the absence of POAG was confirmed with intraocular pressure and cup-disc ratio criteria. We used genotype data and either self-reported glaucoma diagnoses or ICD-10 codes for glaucoma diagnoses from the UK Biobank and the lassosum method to compute a genome-wide POAG PRS. We compared the area under the curve (AUC) for POAG prediction based on ICD codes versus medical records. RESULTS: We reviewed 804 of 996 BioMe and 367 of 1,006 MGB ICD-identified cases. In BioMe and MGB, respectively: positive predictive value was 53% and 55%; negative predictive value was 96% and 97%; sensitivity was 97% and 97%; and specificity was 44% and 53%. Adjusted PRS AUCs for POAG using ICD codes vs. manual record review in BioMe were not statistically different (p≥0.21) by ancestry: 0.77 vs. 0.75 for African, 0.80 vs. 0.80 for Hispanic, and 0.81 vs. 0.81 for European. Results were similar in MGB (p≥0.18): 0.72 vs. 0.80 for African, 0.83 vs. 0.86 for Hispanic, and 0.74 vs. 0.73 for European. CONCLUSIONS: A POAG PRS performed similarly using either manual review or ICD codes in two EHR-linked biobanks; manual assessment of glaucoma status might be unnecessary for some PRS studies. However, caution should be exercised with using ICD codes for glaucoma diagnosis given their low specificity (44-53%) for manually confirmed cases of glaucoma.

Treatment Outcomes for Juvenile Open Angle Glaucoma in Thailand.

PRCIS: Juvenile open angle glaucoma (JOAG) patients with thick central corneas and negative family history were more likely to undergo surgery, mainly trabeculectomy with half requiring additional surgery within 10 years. PURPOSE: To assess the characteristics and treatment outcomes of patients with JOAG in Thailand. PATIENTS AND METHODS: This retrospective, multicenter study included all patients diagnosed with JOAG over 12 years from 2 tertiary hospitals in Bangkok, Thailand. RESULTS: A total of 200 eyes from 104 patients were included in this study. The mean age of onset was 24.0±10.1 years (range: 5-40 y), with male predominance (60.5%). Over 90% of patients had bilateral JOAG and 25% had a positive family history. Negative family history (adjusted odds ratio=4.59, P =0.02) and thick central corneal thickness were surgical predictors (every 10 µm adjusted odds ratio=1.29, P =0.01). Over 70% of cases needed glaucoma surgery. Trabeculectomy with Mitomycin-C was performed on 131 eyes (65.5%) with a cumulative probability of complete success of 71.0%, 57.8%, 39.2%, and 26.9% and qualified success of 86.3%, 73.6%, 64.8%, and 45.7% at 1, 3, 5, and 10 years, respectively. The mean follow-up after surgery was 94.9 ± 69.8 months (range: 13-153 mo). There were no serious postoperative complications. Myopia and the number of baseline glaucoma medications were significantly associated with surgical failure. CONCLUSIONS: Trabeculectomy with mitomycin C was the most common primary surgery performed in Thai patients with JOAG, and successfully reduced intraocular pressure without significant complications. Patients with thicker corneas were more likely to undergo surgery. By 10 years, half of the patients required additional surgery and risk factors for failure included myopia and the number of medications.

Two types of childhood glaucoma secondary to familial exudative vitreoretinopathy.

BACKGROUND: Glaucoma secondary to familial exudative vitreoretinopathy presents as angle closure by either neovascular or non-neovascular mechanisms. We analyze the presentation and outcomes of two types of childhood glaucoma secondary to familial exudative vitreoretinopathy (FEVR). METHODS: This retrospective cross-sectional study included all patients <18 years of age diagnosed with glaucoma after or concurrently with a diagnosis of FEVR between 2010 and 2020 from Queen Sirikit National Institute of Child Health in Bangkok, Thailand. Two groups were analyzed: neovascular or non-neovascular angle-closure status. Primary outcome measures were final visual acuity and intraocular pressure (IOP) in both groups. RESULTS: Of 144 FEVR patients, 8 children (5.5%; 11 eyes, 3 bilateral cases) developed childhood glaucoma. Mean time between FEVR presentation and glaucoma was 42.2 ± 40.0 months. In the neovascular group, 3 of 9 eyes presented with glaucoma at FEVR diagnosis; 3 of 9 eyes (33%) required glaucoma surgery. In the non-neovascular group, 2 eyes presented with acute angle closure secondary to a phacomorphic lens. Both were treated with trabeculectomy, with resolution of pupillary block. All eyes had stage 4B FEVR or greater. Six of 8 eyes had stable or better visual acuity, and 10 eyes (91%) had IOP <21 mm Hg at final follow-up. CONCLUSIONS: Childhood glaucoma secondary to FEVR is a rare complication caused by later stages of the disease. It may present as neovascular or non-neovascular angle closure, often requiring complex care. Therefore, awareness and adequate management of FEVR can help prevent additional morbidity from childhood glaucoma.

Investigating public behavior with artificial intelligence-assisted detection of face mask wearing during the COVID-19 pandemic.

OBJECTIVES: Face masks are low-cost, but effective in preventing transmission of COVID-19. To visualize public's practice of protection during the outbreak, we reported the rate of face mask wearing using artificial intelligence-assisted face mask detector, AiMASK. METHODS: After validation, AiMASK collected data from 32 districts in Bangkok. We analyzed the association between factors affecting the unprotected group (incorrect or non-mask wearing) using univariate logistic regression analysis. RESULTS: AiMASK was validated before data collection with accuracy of 97.83% and 91% during internal and external validation, respectively. AiMASK detected a total of 1,124,524 people. The unprotected group consisted of 2.06% of incorrect mask-wearing group and 1.96% of non-mask wearing group. Moderate negative correlation was found between the number of COVID-19 patients and the proportion of unprotected people (r = -0.507, p<0.001). People were 1.15 times more likely to be unprotected during the holidays and in the evening, than on working days and in the morning (OR = 1.15, 95% CI 1.13-1.17, p<0.001). CONCLUSIONS: AiMASK was as effective as human graders in detecting face mask wearing. The prevailing number of COVID-19 infections affected people's mask-wearing behavior. Higher tendencies towards no protection were found in the evenings, during holidays, and in city centers.

Characteristics of road traffic mortality and distribution of healthcare resources in Thailand.

Road traffic mortalities (RTMs), a leading cause of death globally, mostly occur in low- and middle-income countries, and having sufficient healthcare resources could lower the number of these fatalities. Our study aimed to illustrate the incidence of RTMs per 100,000 population and to compare the distribution of healthcare resources from 2011 to 2021 with rates of RTMs in the 77 provinces of Thailand. We divided the population into adults (≥ 15 years) and children (0-14 years). Lorenz curve and Gini coefficient were used to measure the level of distribution and equality of hospital resources and in relation to RTMs across the country. The average number of deaths was 30.34 per 100,000 per year, with male predominance. The RTM rates for adults and children were 32.71 and 19.08 per 100,000 respectively, and motorcycle accidents accounted for the largest percentage of deaths across all age groups. The Gini coefficient showed that operating rooms (0.42) were the least equally distributed hospital resource, while physicians were the most equally distributed (0.34). Anomalies were identified between the distribution of RTMs and available hospital resources. We hope our study will be beneficial in reallocating these resources more fairly to reflect the different numbers of traffic accidents in each province with the aim of reducing lower traffic-related deaths.

Effects of digital devices and online learning on computer vision syndrome in students during the COVID-19 era: an online questionnaire study.

PURPOSE: Computer vision syndrome (CVS) describes a group of eye and vision-related problems that result from prolonged digital device use. This study aims to assess the prevalence and associated factors of CVS among students during the lockdown resulting from the COVID-19 pandemic. METHODS: A cross-sectional, online, questionnaire-based study performed among high school students in Thailand. RESULTS: A total of 2476 students, with mean age of 15.52±1.66 years, were included in this study. The mean number of hours of digital device use per day (10.53±2.99) increased during the COVID-19 pandemic compared with before its advent (6.13±2.8). The mean number of hours of online learning was 7.03±2.06 hours per day during the pandemic. CVS was found in 70.1% of students, and its severity correlated with both the number of hours of online learning and the total number of hours of digital device usage (p<0.001). Multiple logistic regression analysis revealed that the factors associated with CVS included age ≤15 years (adjusted OR (AOR)=2.17), overall digital device usage >6 hours per day (AOR=1.91), online learning >5 hours per day (AOR=4.99), multiple digital device usage (AOR=2.15), refractive errors (AOR=2.89), presence of back pain (AOR=2.06) and presence of neck pain (AOR=2.36). CONCLUSIONS: The number of hours of digital device usage increased during lockdown. Over 70% of children had CVS, whose associated factors, including hours of digital device usage, hours of online learning, ergonomics and refractive errors, should be adjusted to decrease the risk of acquiring this condition. Online learning will remain, along with CVS, after this pandemic, and we hope our research will be taken into account in remodelling our education system accordingly.

Diagnostic performance of anterior segment optical coherence tomography in detecting plateau iris.

Objective: To evaluate the diagnostic performance of manual grading of anterior segment optical coherence tomography (AS-OCT) in detection of plateau iris configuration (PIC) based on the presence of standardised ultrasound biomicroscopy (UBM) criteria in at least two quadrants; namely, clinical diagnosis of PIC (DxPIC). Methods and analysis: In this cross-sectional study, paired AS-OCT and UBM images were evaluated by three glaucoma specialists. AS-OCT was classified into two mechanisms, PIC versus non-PIC, of primary angle closure disease (PACD) and AS-OCT-PIC diagnostic performance was tested with DxPIC. Results: One hundred and seventy-nine eyes of 142 patients were enrolled for analysis, and DxPIC was found in 85 eyes (47.49%). Intraobserver agreement rates of AS-OCT classification by the graders were 0.77, 0.701 and 0.742 (all p<0.001), and interobserver agreement rates, between a senior glaucoma specialist and the other two glaucoma specialists, were 0.68 and 0.702 (all p<0.001). Plateau iris was classified in AS-OCT images by the three graders, rated 32.96%-39.1% and 24.58%-34.08% in the horizontal and vertical axes, respectively. Diagnostic performance was analysed, yielding sensitivity ranging from 56.47% to 77.78%, and specificity of 48.94% to 64.29%. We applied disease prevalence of 30%, revealing positive predictive values varying from 32.16% to 44.44%, and negative predictive values of 72.4% to 85.71%. Accuracy ranged from 51.2% to 65%. Agreement between the two devices was fair, kappa range 0.31-0.351. Conclusion: Performance of manual grading of AS-OCT in detection of DxPIC was relatively poor; therefore, unadjusted AS-OCT does not appear to be good for manual PIC screening in PACD patients and cannot serve as a substitute for UBM in PIC detection.

Economic Evaluations of Artificial Intelligence in Ophthalmology.

ABSTRACT: Artificial intelligence (AI) is expected to cause significant medical quality enhancements and cost-saving improvements in ophthalmology. Although there has been a rapid growth of studies on AI in the recent years, real-world adoption of AI is still rare. One reason may be because the data derived from economic evaluations of AI in health care, which policy makers used for adopting new technology, have been fragmented and scarce. Most data on economics of AI in ophthalmology are from diabetic retinopathy (DR) screening. Few studies classified costs of AI software, which has been considered as a medical device, into direct medical costs. These costs of AI are composed of initial and maintenance costs. The initial costs may include investment in research and development, and costs for validation of different datasets. Meanwhile, the maintenance costs include costs for algorithms upgrade and hardware maintenance in the long run. The cost of AI should be balanced between manufacturing price and reimbursements since it may pose significant challenges and barriers to providers. Evidence from cost-effectiveness analyses showed that AI, either standalone or used with humans, was more cost-effective than manual DR screening. Notably, economic evaluation of AI for DR screening can be used as a model for AI to other ophthalmic diseases.

Real-world Surgical Outcomes of Primary Angle-closure Glaucoma.

PURPOSE: To evaluate surgical outcomes of the four common procedures utilized for primary angle-closure glaucoma (PACG). METHODS: A retrospective study of survival rate in surgical management of PACG was conducted in a referral eye center. One hundred and ninety-nine eyes from 173 PACG patients were collected for chart review. The procedures used were phacoemulsification (PE), combined PE with goniosynechialysis (PE-GSL), combined PE with trabeculectomy (PE-Trab), and trabeculectomy alone. Failure was defined as postoperative IOP >21 mmHg in patients who needed second surgical intervention or those who had IOP <5 mmHg with loss of light perception. Cumulative survival rates, risk of surgical failure, and complications were analyzed. RESULTS: PE, PE-GSL, PE-Trab, and trabeculectomy were performed in 84 eyes (42.2%), 76 eyes (38.2%), 21 eyes (10.6%), and 18 eyes (9%), respectively. Cumulative survival rates at 60 months were 13%, 55%, 42% and 43%, respectively. Cox regression analysis indicated that each mmHg IOP increased, the risk of surgical failure decreased by 13% (adjusted hazard ratio (HR) 0.87; 95%CI: 0.84-0.93, p<0.001). CONCLUSION: Real-world surgical outcomes of PACG showed that PE alone had a low survival rate of 13% in 60-month follow-up whereas PE-GSL achieved the highest rate of 55%. PE-GSL should be initially considered for management of PACG, since it can restore and sustain the physiologic aqueous pathway and preserve the conjunctiva for future filtering surgery if needed.

Comparative Study of Lamina Cribrosa Thickness Between Primary Angle-Closure and Primary Open-Angle Glaucoma.

PURPOSE: To compare lamina cribrosa thickness (LCT) of primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG) using the enhanced depth-imaging mode of the Heidelberg Spectralis spectral-domain optical coherence tomography (EDI-OCT). PATIENTS AND METHODS: A comparative cross-sectional study was conducted. We enrolled 34 patients with PACG, 38 with POAG, and 62 controls, testing only one eye of each participant. Lamina cribrosa thickness was determined at the center of the optic nerve head using EDI-OCT. Nine points of LCT were measured, and LCT averages were analyzed. RESULTS: Mean age, number of glaucoma medications, current intraocular pressure (IOP), cup to disc ratio, and visual field indices, were not significantly different between PACG and POAG eyes. The maximum IOP (SD) was higher in PACG than in POAG, at 32.5 (10.46) vs 25.05 (6.42) mmHg (p = 0.001), and LCTs were significantly different among the PACG, POAG and control groups. Mean (SD) LCTs were 226.99 (31.08), 257.17 (19.46), and 290.75 (28.02) µm, respectively (p < 0.001). Lamina cribrosa thickness was correlated with mean deviation of the visual field (p = 0.001; correlation coefficient, rs = 0.347), while it was inversely correlated with maximum IOP (p < 0.001; correlation coefficient, rs = -0.592). Linear regression analysis revealed that LCT was inversely related to age (p = 0.008), female (p = 0.018), and maximum IOP (p = 0.002). LCT was marginally related to visual field MD (p = 0.053). CONCLUSION: Glaucomatous eyes had thinner LCT than controls, and maximum IOP was inversely correlated to the LCT. PACG eyes had higher maximum IOP and thinner LCT than POAG ones. In living eye, EDI-OCT emphasizes the pressure-dependent mechanism of glaucoma on lamina cribrosa deformation and the higher IOP-loaded stress which leads to a greater lamina cribrosa strain.

Deep Learning for Anterior Segment Optical Coherence Tomography to Predict the Presence of Plateau Iris.

Purpose: The purpose of this study was to evaluate the diagnostic performance of deep learning (DL) anterior segment optical coherence tomography (AS-OCT) as a plateau iris prediction model. Design: We used a cross-sectional study of the development and validation of the DL system. Methods: We conducted a collaboration between a referral eye center and an informative technology department. The study enrolled 179 eyes from 142 patients with primary angle closure disease (PACD). All patients had remaining appositional angle after iridotomy. Each eye was scanned in four quadrants for both AS-OCT and ultrasound biomicroscopy (UBM). A DL algorithm for plateau iris prediction of AS-OCT was developed from training datasets and was validated in test sets. Sensitivity, specificity, and area under the receiver operating characteristics curve (AUC-ROC) of the DL for predicting plateau iris were evaluated, using UBM as a reference standard. Results: Total paired images of AS-OCT and UBM were from 716 quadrants. Plateau iris was observed with UBM in 276 (38.5%) quadrants. Trainings dataset with data augmentation were used to develop an algorithm from 2500 images, and the test set was validated from 160 images. AUC-ROC was 0.95 (95% confidence interval [CI] = 0.91 to 0.99), sensitivity was 87.9%, and specificity was 97.6%. Conclusions: DL revealed a high performance in predicting plateau iris on the noncontact AS-OCT images. Translational Relevance: This work could potentially assist clinicians in more practically detecting this nonpupillary block mechanism of PACD.

Longitudinal Screening for Diabetic Retinopathy in a Nationwide Screening Program: Comparing Deep Learning and Human Graders.

OBJECTIVE: To evaluate diabetic retinopathy (DR) screening via deep learning (DL) and trained human graders (HG) in a longitudinal cohort, as case spectrum shifts based on treatment referral and new-onset DR. METHODS: We randomly selected patients with diabetes screened twice, two years apart within a nationwide screening program. The reference standard was established via adjudication by retina specialists. Each patient's color fundus photographs were graded, and a patient was considered as having sight-threatening DR (STDR) if the worse eye had severe nonproliferative DR, proliferative DR, or diabetic macular edema. We compared DR screening via two modalities: DL and HG. For each modality, we simulated treatment referral by excluding patients with detected STDR from the second screening using that modality. RESULTS: There were 5,738 patients (12.3% STDR) in the first screening. DL and HG captured different numbers of STDR cases, and after simulated referral and excluding ungradable cases, 4,148 and 4,263 patients remained in the second screening, respectively. The STDR prevalence at the second screening was 5.1% and 6.8% for DL- and HG-based screening, respectively. Along with the prevalence decrease, the sensitivity for both modalities decreased from the first to the second screening (DL: from 95% to 90%, p = 0.008; HG: from 74% to 57%, p < 0.001). At both the first and second screenings, the rate of false negatives for the DL was a fifth that of HG (0.5-0.6% vs. 2.9-3.2%). CONCLUSION: On 2-year longitudinal follow-up of a DR screening cohort, STDR prevalence decreased for both DL- and HG-based screening. Follow-up screenings in longitudinal DR screening can be more difficult and induce lower sensitivity for both DL and HG, though the false negative rate was substantially lower for DL. Our data may be useful for health-economics analyses of longitudinal screening settings.

Clinical presentation and treatment outcomes of primary ocular adnexal MALT lymphoma in Thailand.

BACKGROUND: Primary ocular adnexal extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (POML) is the most common subtype of lymphoma involving the eyes in Thailand. We sought to assess the characteristics and treatment outcomes of patients with POML in Thailand. METHODS: We retrospectively reviewed patient data and included patients diagnosed with POML between January 2004 and December 2016 at Chiang Mai University Hospital and King Chulalongkorn Memorial Hospital, Thailand. We collected and analyzed patients' clinical characteristics and treatment outcomes. RESULTS: Among 146 patients with lymphoma involving the eyes, 121 (82%) were diagnosed with POML. Sixty-four (52.9%) were women with median age 58 (range, 22-86) years. The most common presenting symptom was orbital mass (71.1%). Common sites of origin were the orbit (46.3%) and lacrimal gland (34.7%). At presentation, 22.3% of patients had bilateral eye involvement. About half of patients had stage I disease (N=59, 56.2%) and 20% had stage IV. Most patients (73.3%) had a low-risk International Prognostic Index. Radiotherapy was the main treatment for patients with limited-stage disease (66.7% in stage I and 56.5% in stage II). The overall response rate was 100% with complete response rates 80%, 77.3%, and 64.7% for stages I, II, and IV, respectively. Five-year progression-free survival (PFS) and overall survival were 66.1% and 94.0%, respectively. For patients with limited-stage disease, radiotherapy significantly improved PFS compared with treatment not involving radiotherapy (5-year PFS 89.9% vs. 37.3%, P=0.01). CONCLUSION: We revealed that POML has good response to treatment, especially radiotherapy, with excellent long-term outcome.

Recovery of a Disinserted Medial Rectus Muscle after Pterygium Surgery.

PURPOSE: To report a case of recovery of a medial rectus which was accidentally disinserted after surgical treatment of a recurrent pterygium. METHOD: Report of a case of inadvertent medial rectus disinsertion after pterygium excision at a secondary care hospital which was referred to a tertiary care hospital in Northern Thailand. RESULT: A 40-year-old healthy woman was referred by a general ophthalmologist at a secondary care center to our hospital. She had undergone recurrent pterygium excision with amniotic membrane transplantation on the nasal side of her right eye. Immediately after the last operation, she complained of horizontal binocular diplopia. On the first postoperative day, the patient could not adduct the eye beyond the primary position. Her measurements in primary position were 45 prism diopters of right exotropia on distant and near. The diagnosis of iatrogenic medial rectus disinsertion was made. Three weeks after pterygium excision, revision surgery was performed; the medial rectus was found and reattached to its normal insertion site. On the first postoperative day, the patient referred a small vertical diplopia in the primary position. Orthoptic examination five months post-operatively demonstrated orthotropia and absence of diplopia in primary position, but minimal horizontal diplopia in right gaze. CONCLUSIONS: Accidental rectus muscle disinsertion after pterygium excision surgery is a serious but rare postoperative complication of pterygium surgery. Great care should be taken intraoperatively to avoid this complication. Reattachment of the disinserted medial rectus will produce a satisfactory resolution of the problem.