Deep learning versus human graders for classifying diabetic retinopathy severity in a nationwide screening program.

Deep learning algorithms have been used to detect diabetic retinopathy (DR) with specialist-level accuracy. This study aims to validate one such algorithm on a large-scale clinical population, and compare the algorithm performance with that of human graders. A total of 25,326 gradable retinal images of patients with diabetes from the community-based, nationwide screening program of DR in Thailand were analyzed for DR severity and referable diabetic macular edema (DME). Grades adjudicated by a panel of international retinal specialists served as the reference standard. Relative to human graders, for detecting referable DR (moderate NPDR or worse), the deep learning algorithm had significantly higher sensitivity (0.97 vs. 0.74, p < 0.001), and a slightly lower specificity (0.96 vs. 0.98, p < 0.001). Higher sensitivity of the algorithm was also observed for each of the categories of severe or worse NPDR, PDR, and DME (p < 0.001 for all comparisons). The quadratic-weighted kappa for determination of DR severity levels by the algorithm and human graders was 0.85 and 0.78 respectively (p < 0.001 for the difference). Across different severity levels of DR for determining referable disease, deep learning significantly reduced the false negative rate (by 23%) at the cost of slightly higher false positive rates (2%). Deep learning algorithms may serve as a valuable tool for DR screening.

Erratum: Author Correction: Deep learning versus human graders for classifying diabetic retinopathy severity in a nationwide screening program.

[This corrects the article DOI: 10.1038/s41746-019-0099-8.].

Central corneal thickness changes following manual small incision cataract surgery versus phacoemulsification for white cataract.

Aim: To assess the central corneal thickness (CCT) and endothelial cell loss after manual small-incision cataract surgery and phacoemulsification in patients with white cataract. Material and methods: This is a comparative, prospective, non-randomized study on 42 patients with white cataract, who underwent cataract surgery. The patients were divided into manual small-incision cataract surgery (21 eyes, MSICS group) and phacoemulsification cataract surgery group (21 eyes, phaco group). The endothelial cell density (ECD), central cornea thickness (CCT), and corrected distance visual acuity (CDVA) were evaluated at 1 day, 1 week, 4 weeks, and 3 months postoperatively. The results of 20 cases of nuclear sclerosis grade II-III (LOCS III) who underwent phacoemulsification by the same surgeon were also compared. Propensity scoring was used to adjust for confounding by selection bias. Results: The CCT increased after surgery in both groups. The thickness was greater in the phaco group on first day postoperatively (73 µ increase in MSICS group and 138 µ in phaco group, p=0.008) and it returned to preoperative levels 1 month postoperatively. The endothelial cell loss was lower in the MSICS group at 3 months postoperatively (11.8% in MSICS group and 15.8% in phaco group, p=0.111). The CDVA was not different in both groups at 1 week and 4 weeks postoperatively (p>0.05). Conclusions: Manual small-incision cataract surgery for white cataract provided less central corneal thickness changes compared to conventional phacoemulsification. Abbreviations: CCT = central corneal thickness; ECD = endothelial cell density; CDVA = corrected distance visual acuity; APT = absolute phacoemulsification time; EPT = effective phacoemulsification time; MSICS = Manual small-incision cataract surgery in white cataract; Phaco II = Phacoemulsification in white cataract; Phaco I = phacoemulsification in NS 2 + Cataract; Phaco = Phacoemulsification in white cataract; APACRS = Asia-Pacific Association of Cataract and Refractive Surgeons.

Comparison of a new optical biometer and a standard biometer in cataract patients.

BACKGROUND: Cataract surgery is the most common surgical procedure in ophthalmology. Biometry data and accurate intraocular lens (IOL) calculations are very important in achieving the desired refractive outcomes. The aim of this study was to compare measurements using a new optical low coherence reflectometry (OLCR) biometer (OA-2000) and the gold standard partial coherence interferometry (PCI) optical biometer (IOLMaster 500). METHODS: Ocular biometry of cataract patients were measured by the OA-2000 and IOLMaster 500 to compare keratometry (K), axial length (AL), anterior chamber depth (ACD), white-to-white (WTW) diameter, and IOL power using the SRK/T formula. RESULTS: One hundred and two eyes of 68 cataract patients were evaluated with the two optical biometers. The mean values of the AL, K, ACD, and WTW differed very little (OCLR biometer, 23.12 mm, 44.50 diopters (D), 3.06, and 11.64 mm, respectively; PCI biometer, 23.18 mm, 44.6 D, 3.15, and 11.86 mm, respectively), but the differences were significant (all, p ≤ 0.05). The AL, K, and ACD showed excellent correlations (r = 0.999, 0.980, and 0.824, respectively; all p < 0.001); however, there was a weak correlation of the WTW diameter between the two devices (r = 0.256). The IOL powers using the SRK-T formula derived from both instruments were very similar, with an excellent correlation (r = 0.989). The mean difference between the two instruments was 0.32 D. CONCLUSIONS: The OLCR biometer showed very a strong agreement with the standard PCI optical biometer for almost all ocular biometry measurements, except for the WTW diameter. TRIAL REGISTRATION: TCTR20160614003; date 06/09/2016; 'retrospectively registered'.

A knotless, one-haptic fixation of posterior chamber intraocular lenses: one-year results.

AIM: To assess the results of a modified technique for scleral fixation of a posterior chamber intraocular lens (IOL) in eyes which had deficient of posterior capsular support. METHODS: This retrospective study was comprised of ten patients with deficient posterior capsular support who underwent one-haptic fixation of posterior chamber IOLs, between February 2010 and October 2011. IOL as implanted with one haptic supported on the capsular remnant and the other haptic drawn into the sulcus by anchoring suture without a knot. All patients were evaluated for pre- and postoperative visual acuity, lens centration, intra-and postoperative complications. RESULTS: A knotless, one-haptic fixation of posterior chamber IOLs has successfully been performed on ten eyes. All cases had inadequate capsular support (i.e. a capsular tear ranged from 5 to 7 clock hours). The average age was 74.25±8.87y (SD). The average postoperative uncorrected visual acuity was 0.51 logMAR. Complications included hyphema in one eye, a mild inflammatory reaction in the anterior chamber in two eyes, and a transient rise in IOP in one eye. Neither IOL tilt nor dislocation was observed and there were no later complications. CONCLUSION: In the presence of insufficient capsular support, a knotless, one-haptic fixation of posterior chamber IOLs is a safe and viable option which reduces the operation time, and minimizes postoperative suture-related complications.

Superior subconjunctival anesthesia versus retrobulbar anesthesia for manual small-incision cataract surgery in a residency training program: a randomized controlled trial.

PURPOSE: To evaluate the effectiveness of subconjunctival anesthesia as compared to retrobulbar anesthesia for pain control during manual small-incision cataract surgery (MSICS) performed by third-year residents. DESIGN: A randomized, controlled trial. PATIENTS AND METHODS: A total of 150 patients undergoing routine cataract surgery were randomly assigned to receive either subconjunctival anesthesia (group 1, n = 75) or retrobulbar anesthesia (group 2, n = 75). Third-year residents performed MSICS using the modified Blumenthal technique. Subconjunctival anesthesia was administered by injecting 2% xylocaine with adrenalin into the superior conjunctiva, and retrobulbar anesthesia by injecting 2 mL of 2% xylocaine with adrenalin into the retrobulbar space. We studied the following variables: intraoperative pain score rated on a 100-point visual analog scale (VAS), operative time, and injection and operative complications. RESULTS: A mean age of 69 vs 70 years, an operative time of 47.1 (SD, 9.9) min vs 47.7 (10.9) min, and a median (interquartile range) pain score of 40 (range, 20-70) vs 40 (range, 20-50) were observed in the subconjunctival and the retrobulbar groups, respectively. The injection complication of subconjunctival hemorrhage was significantly higher in the subconjunctival group (25.3%) compared to the retrobulbar group (1.3%). The operative complication rate between groups was not different (P > 0.05). CONCLUSION: Both, superior subconjunctival anesthesia and retrobulbar anesthesia were effective during MSICS when used in a residency training program.

Cost-effectiveness analysis of manual small incision cataract surgery (MSICS) and phacoemulsification (PE).

BACKGROUND: Cataract is the most common cause of blindness, responsible for 50 to 80% of all blindness in South-East Asia. Method of cataract surgery that has cost-effective, low technology procedure and a low complication rate in the shortest amount of time is needed. This study provides the useful resources comparing clinical outcomes and cost of phacoemulsification (PE) and manual small incision cataract surgery (MSICS) based on hospital perspective. OBJECTIVE: To compare the costs and effectiveness of two-cataract-surgery methods, MSICS and PE, using the hospital's perspective. SETTING: Department of Ophthalmology, Phrapoklao hospital, Thailand. MATERIAL AND METHOD: This study was prospective and comparative. Data was collected from medical charts and through patient interviews using data collection forms. Labor material and capital cost were recorded for both surgical methods. The effectiveness was measured in visual acuity (VA), astigmatism and complications occurring at 90 days after surgery. RESULTS: The average total cost was 10,043.81 bath/case for MSICS and 11,590.72 bath/case for PE. After 90 days after surgery, the average VA of MSICS and PE groups were 0.83 +/- 0.225 (0.10-1.00) and 0.76 +/- 0.268 (0.06-1.00). There was no statistically significant difference in both groups. The average astigmatism at 90 days after surgery was 1.01 +/- 0.733 (0.00-3.50) D and 0.99 +/- 0.713 (0.00-4.25) D for MSICS and PE method. The average change in astigmatism was 0.15 and 0.20 D for the MSICS and PE groups. The intraoperative complication was vitreous loss (1.40%) in the PE group. The postoperative complication was corneal edema (5.60%) in the MSICS group. There was no statistically significant difference in the number of postoperative complications in both groups (p = 0.16). CONCLUSION: The effectiveness of MSICS and PE methods was not significantly different, but PE method had higher costs. Therefore, MSICS has better cost-effectiveness than PE thus, MSICS should be a preferred cataract surgery method to PE method, based on the hospital's perspective.

Visual outcome of manual small-incision cataract surgery: comparison of modified Blumenthal and Ruit techniques.

AIM: To compare the efficacy and visual results of the modified Blumenthal and Ruit techniques for manual small-incision cataract surgery (MSICS). METHODS: This was a prospective, non-randomized comparison of 129 patients with senile cataracts scheduled to undergo routine cataract surgery via either a superior scleral tunnel incision, i.e., the Blumenthal technique (group 1, n=64) or a temporal scleral tunnel incision, i.e., the Ruit technique (group 2, n=65). MSICS and intraocular lens implantation were performed through an unsutured 6.5- to 7.0-mm scleral tunnel incision. Uncorrected and corrected visual acuity, intraoperative and postoperative complications, and surgically induced astigmatism calculated by simple subtraction were compared. Patients were examined at 1 day, 1 week, 1 month, and 3 months after surgery. RESULTS: Both groups achieved good visual outcome with minor complications. Three months after surgery, the corrected visual acuity was 0.73 in the Blumenthal group and 0.69 in the Ruit group (P=0.29). The average (SD) postoperative astigmatism was 0.87 (0.62) diopter (D) for the Blumenthal group and 0.86 (0.62) D for the Ruit group. The mean (SD) surgically induced astigmatism was 0.55 (0.45) D and 0.50 (0.44) D for the Blumenthal and Ruit groups, respectively (P=0.52). Common complications were minimal hyphema and corneal edema. There was no statistically significant difference in the complication rate between the groups (P>0.05). CONCLUSION: In MSICS, both the Blumenthal and Ruit techniques achieved good visual outcomes, with low complication rates.

Visual outcome of manual small-incision cataract surgery: comparison of modified Blumenthal and Ruit techniques / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To compare the efficacy and visual results of the modified Blumenthal and Ruit techniques for manual small-incision cataract surgery (MSICS).METHODS: This was a prospective, non-randomized comparison of 129 patients with senile cataracts scheduled to undergo routine cataract surgery via either a superior scleral tunnel incision, i.e., the Blumenthal technique (group 1, n=64) or a temporal scleral tunnel incision, i.e., the Ruit technique (group 2,n=65). MSICS and intraocular lens implantation were performed through an unsutured 6.5-to 7.0-mm scleral tunnel incision. Uncorrected and corrected visual acuity, intraoperative and postoperative complications, and surgically induced astigmatism calculated by simple subtraction were compared. Patients were examined 1 day, 1 week, 1 month, and 3 months after surgery.RESULTS: Both groups achieved good visual outcomes with minor complications. Three months after surgery, the corrected visual acuity was 0.73 in the Blumenthal group and 0.69 in the Ruit group (P=0.29). The average (SD) postoperative astigmatism was 0.87 (0.62) diopter (D) for the Blumenthal group and 0.86 (0.62) D for the Ruit group. The mean (SD) surgically induced astigmatism was 0.55 (0.45) D and 0.50 (0.44) D for the Blumenthal and Ruit groups, respectively (P=0.52). Common complications were minimal hyphema and corneal edema. There was no statistically significant difference in the complication rate between the groups (P>0.05).CONCLUSION: In MSICS, both the Blumenthal and Ruit techniques achieve good visual outcomes, with low complication rates.

Combined 20-gauge and 23-gauge pars plana vitrectomy for the management of posteriorly dislocated lens: a case series.

OBJECTIVE: To present a new surgical approach for the management of posteriorly dislocated lens by using a combination of 20-gauge (20G) and 23-gauge (23G) pars plana vitrectomy. DESIGN: An interventional case series METHODS: This technique was performed on six patients (five men, one woman; mean age, 66.67 years; range, 66-72 years). Two 23G trans-conjunctival sclerotomy ports were created for infusion and illumination along with a 20G sclerotomy port for introducing the vitrectomy probe or fragmatome. RESULTS: This procedure was successfully performed on six eyes. On postoperative day one, the media were clear and the retina could be seen by indirect ophthalmoscopy. Hyphema developed in one eye and resolved within a week. There were no observed cases of retinal tear, wound leakage, hypotony, or endophthalmitis. The post-operative follow-up period ranged from three to twelve months (mean, 8.1 months). By the final visit, two patients had achieved a visual acuity of 20/40 or better, three patients, 20/70, and one patient, 20/200. CONCLUSION: The combination of 20G and 23G pars plana vitrectomy is an efficacious and safe procedure for management of posteriorly dislocated lens.

Sutureless large-incision manual cataract extraction using the kongsap technique: outcome of a prospective study.

AIM: To report the short- and medium-term outcomes of sutureless large-incision manual cataract extraction using the Kongsap (SLIMCE-K) technique. METHODS: This prospective study included 73 eyes of 73 patients who underwent cataract surgery performed by using the SLIMCE-K technique. The postoperative visual acuity, intraoperative and postoperative complications, and endothelial cell loss were evaluated. A follow-up visit, at least 6 months after the surgery, was included in the study. RESULTS: All patients had improved visual acuity after surgery. Uncorrected visual acuity (UCVA) was 6/18 or better in 55 eyes (75.3%) at 1 week postoperatively and in 64 eyes (87.6%) at 6 weeks postoperatively (P=0.09). The best corrected visual acuity (BCVA) was 6/18 or better in 67 eyes (91.8%) at 1 week postoperatively and in 70 eyes (95.9%) at 6 weeks postoperatively. The results remained stable at 3 months and 6 months postoperatively. No significant intraoperative complications were encountered. The endothelial cell loss was 4.8% at the 3-month follow-up examination. CONCLUSION: When performed by an experienced surgeon, SLIMCE-K is a safe and effective procedure that can be performed independent of phacoemulsification machines. It can be used in any nuclear grading of cataract hardness that is common in developing countries.

Visual outcomes and incidence of vitreous loss among third-year ophthalmology residents performing manual small incision cataract surgery / 国际眼科杂志(Guoji Yanke Zazhi)

AIM:To determine the visual outcome and the incidence of vitreous loss in patients undergoing manual small incision cataract surgery(MSICS)by third-year ophthalmology residents.METHODS:Hospital records of 799 consecutive patients undergoing MSICS at Department of Ophthalmology,Prapokklao Hospital by third-year ophthalmology residents between July 2005 and June 2007 were reviewed.Bestcorrected visual acuity(BCVA)were compared between the eyes operated by residents and those operated by the staffs.For the complication of vitreous loss,the study group(patients with vitreous loss)were compared with the control group(patients without vitreous loss)using analytic case-control study.RESULTS:One month postoperatively,91.0%of patients in resident group and 92.5%in the staff group had visual acuity of 6/18 or better.The difference in visual outcome between the two groups was not statistically significant(P =0.526).The incidence of vitreous loss among residents was 5.01%(20/399)and 1.00%(4/400)among the staff.The overall incidence of vitreous loss was 3.0%.The odds that the eyes in the resident group would have an intraoperative complication of vitreous loss were 5.22 times,the odds that the eyes in the staff group would have such a complication(P = 0.002,95%confidential interval(Cl)of relative risk =1.769-15.426).CONCLUSION:Good visual acuity can be achieved after resident perfoming MSICS.The vitreous loss rate in this study is high.

Corneal endothelial cell loss between the Kongsap manual phacofragmentation and phacoemulsification.

OBJECTIVE: To compare corneal endothelial cell loss between the Kongsap manual phacofragmentation and phacoemulsification. MATERIAL AND METHOD: One hundred two eyes with age-related cataract were randomized to undergo either the Kongsap manual phacofragmentation (Group 1, 52 eyes) or phacoemulsification surgery (Group 2, 50 eyes) with implantation of a posterior chamber, foldable, acrylic intraocular lens performed by one surgeon. The main parameters were corneal endothelial cell density (ECD), best corrected visual acuity (BCVA), and intraoperative and postoperative complications. Follow-up visits were scheduled at 1, 4, and 12 weeks. RESULTS: Pre-operatively, the mean ECD in Group 1 was 2,350 +/- 229 cells/mm2 and in Group 2 was 2,429 +/- 263 cells/mm2 (p = 0.112). Mean ECD decrease was 7.61% in Group 1 and 7.19% in Group 2 at the end of 12 weeks. The 95% confidence intervals of the mean differences of the endothelial cell loss at 4 weeks and 12 weeks after surgery were -1.87 to 2.04% and -2.77 to 3.63%, respectively. Mean best-corrected visual acuity at the end of 4 weeks was 0.88 +/- 0.22 in Group 1 and 0.82 +/- 0.24 in Group 2 (p = 0.117). There was no statistical difference between the groups in intra-operative and postoperative complications (p > 0.05). CONCLUSION: The corneal endothelial cell loss after cataract surgery with the Kongsap manual phacofragmentation is equivalent to those of phacoemulsification and both surgical techniques allowed excellent visual results.

Manual sutureless cataract surgery with foldable intraocular lens using the Kongsap technique: the results of 95 cases.

OBJECTIVE: To evaluate the visual outcome and complications of the small incision cataract surgery with foldable intraocular lens implantation using the Kongsap technique. STUDY DESIGN: Prospective, non-comparative study. MATERIAL AND METHOD: This prospective study was conducted at Prapokklao Hospital, Chanthaburi between December 2005 and May 2006. The ninety-five eyes of 95 patients underwent cataract surgery using the Kongsap technique. The best-corrected visual acuity, intra-operative and post operative complications, and the corneal endothelial cell loss were then evaluated. Follow-up visits were scheduled at one week, one month, three months, and six months. RESULTS: Best corrected visual acuity (BCVA) was 20/40 or better in 83 eyes (87.37%) at one week postoperatively, in 86 eyes (90.53%) at one month, in 87 eyes (91.58%) at 3 months, and in 85 eyes (89.48%) at 6 months. The most common intra-operative complication was iris prolapse (7.37%). Other intra-operative complications were posterior capsule rupture (2.11%), transient intracameral bleeding (2.11%), and capsulorhexis tear (2.11%). The most significant post operative complication was transient corneal edema located at the corneal wound, which developed in seven eyes (7.37%). No other significant complications were noted during the six-month follow up period. Mean endothelial cell loss was 5.3% at one month and 7.1% at three months post operatively. CONCLUSION: Manual sutureless cataract surgery with foldable intraocular lens using the Kongsap technique when performed by an experienced surgeon was a safe procedure with good visual recovery and no need for a phaco machine.

Corneal injury by bee sting with retained stinger--a case report.

OBJECTIVE: To report a rare case of corneal injury by bee sting with its complication and management. MATERIAL AND METHOD: A 3-year-old boy, who was attacked by a swarm of bees, was referred for the right eye's corneal ulcer evaluation. RESULTS: Two stingers were found and completely removed with jeweler forceps. Corneal epithelial defect, corneal edema, secondary bacterial keratitis, heterochromia iridis, and internal ophthalmoplegia were identified The corneal edema markedly improved 3 days after removing the retained bee stingers and treatment by topical antibiotics and steroids. The patient was evaluated after 1 week and 1 month and was found with permanent central corneal scar particularly at the area corresponding to the retained stinger The patient had subsequently localized traumatic anterior subcapsular cataract corresponding to where the stinger had penetrated the lens. CONCLUSION: Corneal bee sting injury is an uncommon ocular trauma, but can result in severe sight threatening complication. Even though the response of corneal edema is well inclined to topical steroid, awareness in adjusting the clinical treatment for the particular case needs a scrutinized investigation of the infection.

A comparison of patient pain during cataract surgery with topical anesthesia in Prechop Manual Phacofragmentation versus phacoemulsification.

OBJECTIVE: To compare the pain level and complications during cataract surgery with topical anesthesia in Prechop MPF versus phacoemulsification. STUDY DESIGN: Prospective randomized comparative study. MATERIAL AND METHOD: One hundred patients, undergoing small incision cataract surgery under topical anesthesia, were allocated randomly to perform Prechop MPF (n = 50) or phacoemulsification (n = 50). Patients were asked to rate their pain level on a 10-point visual analog pain scale during the administration of the anesthetic, during the surgery and after surgery. The surgeon recorded his subjective assessment of patient cooperation and surgical complications. RESULTS: The mean pain score during surgery was 1.64 +/- 1.48 (SD) in the prechop MPF group and 0.92 +/- 1.34 (SD) in the phacoemulsification group. The difference between groups was statistically significant (p = .001). There was no significant difference in pain scores for delivery of anesthesia (p = .077), or after surgery (p = .221) and no significant difference in patient cooperation (p = .446) and surgical complications in either group. CONCLUSION: Patients having cataract surgery under topical anesthesia in the prechop MPF group had more intraoperative pain than patients in the phacoemulsification group. However there was no significant difference in patient cooperation and surgical complications between the groups.