A case study in applying artificial intelligence-based named entity recognition to develop an automated ophthalmic disease registry.

PURPOSE: Advances in artificial intelligence (AI)-based named entity extraction (NER) have improved the ability to extract diagnostic entities from unstructured, narrative, free-text data in electronic health records. However, there is a lack of ready-to-use tools and workflows to encourage the use among clinicians who often lack experience and training in AI. We sought to demonstrate a case study for developing an automated registry of ophthalmic diseases accompanied by a ready-to-use low-code tool for clinicians. METHODS: We extracted deidentified electronic clinical records from a single centre's adult outpatient ophthalmology clinic from November 2019 to May 2022. We used a low-code annotation software tool (Prodigy) to annotate diagnoses and train a bespoke spaCy NER model to extract diagnoses and create an ophthalmic disease registry. RESULTS: A total of 123,194 diagnostic entities were extracted from 33,455 clinical records. After decapitalisation and removal of non-alphanumeric characters, there were 5070 distinct extracted diagnostic entities. The NER model achieved a precision of 0.8157, recall of 0.8099, and F score of 0.8128. CONCLUSION: We presented a case study using low-code artificial intelligence-based NLP tools to produce an automated ophthalmic disease registry. The workflow created a NER model with a moderate overall ability to extract diagnoses from free-text electronic clinical records. We have produced a ready-to-use tool for clinicians to implement this low-code workflow in their institutions and encourage the uptake of artificial intelligence methods for case finding in electronic health records.

Overcoming the impact of physiologic tremors in ophthalmology.

PURPOSE: Ophthalmic surgery involves the manipulation of micron-level sized structures such as the internal limiting membrane where tactile sensation is practically absent. All humans have physiologic tremors that are of low amplitude and not discernible to the naked eye; they do not adversely affect the majority of the population's daily functioning. However, during microsurgery, such tremors can be problematic. In this review, we focus on the impact of physiological tremors on ophthalmic microsurgery and offer a comparative discussion on the impact of such tremors on other surgical specialties. METHODS: A single investigator used the MEDLINE database (via PubMed) to search for and identify articles for inclusion in this systematic review. Ten key factors were identified as potentially having an impact on tremor amplitude: beta-blockers, muscle fatigue, robotic systems, handheld tools/micromanipulators, armrests/wrist supports, caffeine, diet, sleep deprivation, consuming alcohol, and workouts (exercise). These key terms were then searched using the advanced Boolean search tool and operators (i.e., AND, OR) available on PubMed: (*keyword*) AND (surgeon tremor OR microsurgery tremor OR hand steadiness OR simulator score). RESULTS: Ten studies attempted to quantify the baseline severity of operator physiologic tremor. Approximately 89% of studies accessing the impact of tremors on performance in regards to surgical metrics reported an improvement in performance compared to 57% of studies concluding that tremor elimination was of benefit when considering procedural outcomes. CONCLUSIONS: Robotic technology, new instruments, exoskeletons, technique modifications, and lifestyle factors have all demonstrated the potential to assist in overcoming tremors in ophthalmology.

An elusive case of malignant optic nerve glioma with a suprasellar mass.

A 67-year-old man with multiple comorbidities presented with 3 weeks of orbital pain, proptosis, and no light perception vision in the left eye. Examination was notable for a left orbital apex syndrome with CN III, VI palsies, an optic neuropathy, and central retinal vein occlusion. Magnetic resonance imaging of the orbits was notable for extensive enhancement, enlargement, and T2 hyperintensity of the optic nerve, with perineural sheath enhancement, and chiasmal hyperintensity. Inflammatory workup and lumbar puncture were unremarkable. No improvement was seen after a 3-day course of intravenous solumedrol. Initial optic nerve biopsy revealed necrotic nerve tissue, macrophage infiltration, increased vascularization, and peripheral gliosis. The volume of tissue was inadequate for genomic analysis. The patient was lost to follow-up but returned 5 months later with right-sided vision loss. Repeat neuroimaging showed a new suprasellar mass and progressive expansion and enhancement of both optic nerves. Biopsies of the suprasellar mass and left nerve at this time were consistent with a high-grade glial neoplasm, WHO grade IV. This is a rare case of glioblastoma involving the optic nerves and suprasellar region. In such cases, molecular profiling can improve diagnosis and may provide for targeted treatments in the future.

Impact of cardiometabolic factors on retinal vasculature: A 3 × 3, 6 × 6 and 8 × 8-mm ocular coherence tomography angiography study.

BACKGROUND: Ocular coherence tomography angiography (OCTA) is available in varying size and resolution. We sought to characterise associations of cardiometabolic factors with retinal microvascular changes using 3 × 3, 6 × 6 and 8 × 8-mm OCTA scans to determine differences in detection with varying scan size. METHODS: Cross-sectional study of 247 cardiovascular patients from a single-centre tertiary-care hospital. Demographic, comorbidity and medication data were obtained. Patients underwent 3 × 3, 6 × 6 and 8 × 8-mm macula OCTA scanning using Carl Zeiss CIRRUS HD-OCT Model 5000. Angioplex and AngioTool software was used to quantify vascular parameters in the superficial capillary plexus. RESULTS: Increasing age, hypertension, dyslipidaemia, diabetes, chronic kidney disease, coronary artery disease and peripheral vascular disease were associated with reductions in vessel density, vessel perfusion, average vessel length and/or junction density in 3 × 3-mm OCTA (P < .05 for all). Conversely, smoking was associated with increased vessel density, vessel length and junction density in 3 × 3-mm OCTA (P < .05 for all). Associations of vessel abnormalities with cardiometabolic factors were progressively weakened and statistically attenuated in 6 × 6 and 8 × 8-mm OCTA scans. In multivariate analyses, dyslipidaemia remained an independent predictor of reduced vessel density, average vessel length and junction density (P < .05). CONCLUSIONS: Cardiometabolic factors are associated with multiple retinal microvascular changes in 3 × 3-mm OCTA scans. These associations were weakened and progressively attenuated in OCTA scans of larger 6 × 6 and 8 × 8-mm size. These findings advance our understanding of microcirculatory dysfunction and may have future implications for the screening and management of patients with cardiometabolic risk factors. Additional studies are required to further investigate these important associations.

Periorbital desmoplastic squamous cell carcinoma.

Desmoplasia is the formation of a dense collagenous stroma around a neoplasm. It occurs in a variety of malignancies including squamous cell carcinoma (SCC). While desmoplasia is uncommonly seen in cutaneous SCC, it is an independent risk factor for recurrence and metastasis. We report a case series of desmoplastic SCC in the periorbital region. Seven cases were identified: the median age was 68, four were men. The mean follow-up was 48 months. Two patients (29%) had aggressive local recurrence: one required salvage surgery including orbital exenteration, parotidectomy, and neck dissection to excise involved parotid and cervical lymph nodes; the other required repeat excision and adjuvant radiotherapy. Desmoplastic SCC is an uncommon but highly aggressive subtype. In the periorbital region, due to the high risk of orbital invasion, it is potentially sight and life-threatening.

The Observational Physician and surGEon Automobile Response (TOP GEAR) survey.

OBJECTIVE: To determine whether surgeons and junior doctors intending to pursue careers in surgery are more likely to purchase more expensive vehicles and to replace them sooner than colleagues of similar seniority pursuing non-surgical careers. DESIGN AND SETTING: Survey of practising medical officers at an Australian tertiary referral hospital. MAIN OUTCOME MEASURES: Car value; proportion of doctors who bought their car new; median time to replacement of vehicle. RESULTS: 154 doctors participated in the survey (17% response rate). 49% were interns, residents or unaccredited registrars, 18% were accredited registrars or fellows, and 31% were consultants; 40% of respondents were surgical trainees or consultants. 59% of surgical trainees and consultants purchased their car new, compared with 38% of non-surgical doctors (P = 0.013); 52% of doctors in the junior surgeon group purchased their car new, compared with 28% of non-surgeon junior doctors (P = 0.019). Median car value was $16 500 (IQR, $9350-37 000) for surgeons and $8500 (IQR, $4400-14 100) for non-surgeons (P < 0.001); 30% of surgeons owned cars valued at more than $50 000, compared with 6% of non-surgeons (P = 0.025). The median time to replacement was 5-7 years for surgeons and 7-10 years for non-surgeons (P < 0.001). CONCLUSIONS: Surgeons more frequently purchase their cars new and replace their cars earlier than non-surgeons, and the median value of their vehicles is higher. These findings were consistent across all levels of seniority.

Bilateral orbital compartment syndrome in a patient with disseminated intravascular coagulation.

A 39-year-old male developed bilateral periorbital oedema and tense orbits in keeping with orbital compartment syndrome (OCS) shortly after presenting to the emergency department for uncontrollable epistaxis. Bilateral lateral canthotomy and inferior cantholysis was performed within 30 minutes of onset, with the left side further decompressed via superior cantholysis. Computed tomography demonstrated bilateral proptosis and optic nerve stretch, but no intraorbital haemorrhage or haematoma. Laboratory findings were consistent with disseminated intravascular coagulation (DIC) and sepsis of unknown origin. The right visual acuity recovered to 6/6 -2 from counting fingers, but the left eye failed to improve beyond light perception. This unique case of OCS is the first associated with DIC which had no evidence of intraorbital haemorrhage.

Endoscopic Endonasal-Assisted Resection of Orbital Schwannoma.

Orbital schwannomas are rare and despite a variety of external surgical approaches previously utilized, removal of tumors located in the deep orbital apex remains challenging. The endoscopic endonasal approach has been used increasingly for various apical tumours, but few describe this technique for orbital schwannomas. The authors describe 2 cases of orbital schwannoma removed via an endoscopic endonasal assisted approach. The first patient was a 31-year-old Cantonese female who was found to have an 11 × 8 × 8 mm right orbital apical schwannoma which was removed using an endoscopic endonasal sphenoethmoidal approach. The second patient was a 78-year-old white male who had a 28 × 17 × 18 mm orbital schwannoma removed via a transcaruncular and endoscopic endonasal-assisted approach. These findings suggest that the use of an endonasal approach may facilitate the safe removal of selected medially located orbital schwannomas whose posterior margins involve the orbital apex.

Perineural Invasion of the Orbit by Neurotropic Nondesmoplastic Melanoma.

The authors report a case of neurotropic nondesmoplastic melanoma involving the ophthalmic division of the trigeminal nerve and the cavernous sinus in a patient with recurrent scalp melanoma. This case highlights the importance of earlier diagnosis of local recurrence of melanoma and the rare association of neurotropic melanoma and orbital metastasis.

Tissue Engineering in Ophthalmology: Implications for Eyelid Reconstruction.

PURPOSE: Bioengineering aims to produce functional tissue replacements to repair defects and has been widely investigated over the past few decades. We aimed to review the available literature on the application of tissue engineering in ophthalmology, with a particular focus on ophthalmic plastic surgery and potential applications for eyelid reconstruction. METHODS: A literature search was performed on the MEDLINE database using the keywords "bioengineering," "tissue engineering," and "ophthalmology." Articles written in English were included. RESULTS: There is a substantial body of work on tissue engineering of the cornea. Other structures in ophthalmology investigated include the conjunctiva, lacrimal gland, and orbital bone. We also discuss the potential application of tissue engineering in eyelid reconstruction. CONCLUSION: Tissue engineering represents the future of regenerative and reconstructive medicine, with significant potential applications in ophthalmic plastic surgery.

Endoscopic Transretracaruncular-Middle Meteas Tract for Insertion of a Porous Polyethylene-Coated Jones Tube.

PURPOSE: The purpose of this article is to describe a modified lacrimal bypass with a porous polyethylene-coated Jones tube. METHODS: A total of 180 patients (180 eyes) with a nonreconstructable lacrimal obstruction underwent lacrimal bypass with a porous polyethylene-coated Jones tube through a retrocaruncular-middle meatus tract approach with endoscopic assistance. All patients were followed up at least for 24 months. Success rate of lacrimal bypass was analyzed and complications were recorded. RESULTS: A total of 174 patients were finally included. Duration of surgery ranged from 28 to 47 minutes (mean 37.2 ±â€Š4.2 minutes). The mean duration of follow-up was 30.0 ±â€Š6.4 months (range 24-48 months). The mean tube length was 23.2 ±â€Š1.9 mm (range 20-28 mm). At the final review, complete success was achieved in 138 (79.3%) patients. Moderate success was achieved in 23 (13.2%) patients, and 13 (7.5%) patients failed. Of the 161 patients successfully treated, 24 patients underwent revision surgery to excise granulomas (15 patients) or adjust tube position (9 patients). The complications included granuloma proliferation around the openings of the tube (28 eyes), downward displacement of the tube (17 eyes), and ocular discomfort (15 eyes). The majority of downward tube migration occurred in patients who had a prior history of dacryocystorhinostomy. The treatment failed for 5 patients because of repeated granulomas covering the nasal tube openings, and the treatment failed for 8 patients because of downward displacement of the tube. CONCLUSIONS: Our procedure appears to be an effective method for closed insertion of a porous polyethylene-coated Jones.

Haemangiopericytoma of the lacrimal sac.

Haemangiopericytomas (HPCs) are rare tumours which infrequently occur in the lacrimal sac. Only 8 cases of lacrimal sac HPC have previously been reported. The authors report 2 additional cases presenting clinically with epiphora and a mass. One case recurred 3 times during an 18-year period. The other case did not recur during 51 months of follow-up. The tumours showed immunohistochemical features consistent with a diagnosis of HPC. The authors recommend wide excision for these tumours and careful long-term follow-up to detect recurrence which is not uncommon.

Periocular Squamous Cell Carcinoma: TNM Staging and Recurrence.

PURPOSE: To analyze the TNM stage, management, and recurrence rates of patients with histologically confirmed squamous cell carcinoma (SCC) of the eyelid. DESIGN: Retrospective case series from 3 Australian centers. PARTICIPANTS: A total of 254 cases of eyelid SCC from 254 patients (median age, 73 years; range, 28-102 years; 159 were male). METHODS: Tumors were staged according to The American Joint Committee on Cancer 7th edition TNM criteria for eyelid carcinoma. MAIN OUTCOME MEASURES: Outcomes and recurrence rates according to TNM stage at presentation. RESULTS: A total of 25 cases (9.8%) were recurrent tumors. TNM classifications were as follows: T1N0M0, 74 patients (29.1%); T2aN0M0, 92 patients (36.2%); T2bN0M0, 50 patients (19.7%); T3aN0M0, 31 patients (12.2%); T3bN0M0, 5 patients (2.0%); T2bN0M1, 1 patient (0.4%); and T3bN1M1, 1 patient (0.4%). Perineural invasion (PNI) was present histologically in 8.3% of cases. Treatment modalities included Mohs microsurgery (31.1%), wide local excision (WLE) with paraffin section control (21.7%), WLE with frozen-section control (19.3%), and excision without margin control (24.4%). Three cases did not receive treatment. Median follow-up was 40 months (range, <1-132 months). Local recurrence occurred in 17 treated patients (6.8%). The recurrence rate was 5.3% (12/226 patients) for primary tumors and 20% (5/25 patients) for recurrent tumors (P = 0.019). Four patients (1.6%) died of their disease during follow-up. Higher T stage was significantly associated with both PNI (P = 0.035) and local recurrence (P < 0.001). We could not identify a T-stage threshold below which there was no risk of recurrence, as evidenced by 3 T1 primary tumors that recurred. CONCLUSIONS: Higher T stage was significantly associated with local recurrence, and recurrent tumors had a 4-fold increased risk of further recurrence compared with primary tumors. Therefore, it may be reasonable to consider sentinel lymph node biopsy or close nodal surveillance and follow-up for patients with recurrent or high T-stage tumors. Of note, we could not identify a T-stage threshold below which there was no risk of recurrences; therefore, clinicians should be aware of the potential for low T-stage tumors to recur.

Management of periorbital basal cell carcinoma with orbital invasion.

Basal cell carcinoma (BCC) is the most common eyelid malignancy; however, orbital invasion by periocular BCC is rare, and management remains challenging. Established risk factors for orbital invasion by BCC include male gender, advanced age, medial canthal location, previous recurrences, large tumor size, aggressive histologic subtype and perineural invasion. Management requires a multidisciplinary approach with orbital exenteration remaining the treatment of choice. Globe-sparing treatment may be appropriate in selected patients and radiotherapy and chemotherapy are often used as adjuvant therapies for advanced or inoperable cases, although the evidence remains limited. We aim to summarize the presentation and treatment of BCC with orbital invasion to better guide the management of this complex condition.

Accuracy of Biopsy in Subtyping Periocular Basal Cell Carcinoma.

PURPOSE: To determine the accuracy of initial biopsy in the diagnosis of basal cell carcinoma (BCC) histologic subtype. METHODS: Retrospective histopathologic review of patients with a diagnosis of primary periocular BCC from 2006 to 2013 inclusive. RESULTS: A total of 174 primary BCCs were identified. BCCs were classified as nodular, superficial, or aggressive (including mixed cases with an aggressive component). Punch biopsies were used in 41% of cases, while the remaining patients underwent shave or incision biopsies. The final histologic subtypes at excision were nodular (59%), superficial (7%), nodular and superficial (7%), and aggressive (51%). The overall concordance between the BCC subtype identified in the biopsy specimen and the subsequent excision specimen was 54%. In total, there were 51 cases (29%) of BCC, which included aggressive subtypes, of which 52% of initial biopsies failed to detect an aggressive component. There were 45 cases (26%) of mixed BCC, and an aggressive histologic subtype was present in 73% of these cases. CONCLUSIONS: The accuracy of initial biopsy for BCC histologic subtype at excision is highest for nodular BCC. For aggressive BCC, biopsy was able to detect the aggressive component in only 48% of cases. This may have implications for choice of treatment modality.

Endocrine mucin-producing sweat gland carcinoma of the eyelid.

An elderly woman was incidentally noted to have a nodular mass on the upper eyelid, whilst under investigation for cataracts. Punch biopsy of this presumed basal cell carcinoma revealed it to be endocrine mucin-producing sweat gland carcinoma (EMPSGC). The tumour extended to the deep dermal layer and comprised solid nests with foci of cystic and papillary change, and additional cytoplasmic and focal extracellular mucin deposits. Immunohistochemistry confirmed epithelial lineage and neuroendocrine differentiation, and adjacent tissue invasion. The tumour was excised completely with Mohs micrographic surgery with no recurrence after 8 months. EMPSGC is a low-grade sweat gland carcinoma with variable neuroendocrine differentiation, a solid, papillary, or cystic growth pattern, and a predilection for the eyelid of elderly women [Am J Surg Pathol 29:1330-1339, 2005]. There have been 54 previously documented cases of EMPSCG. We report an additional case and review the literature.

Histological subtypes of periocular basal cell carcinoma.

BACKGROUND: To determine the proportion of different subtypes of periocular BCC in South Australia. DESIGN: Retrospective review. PARTICIPANTS: One thousand seven hundred thirteen consecutive periocular basal cell carcinoma (BCC) excision specimens. METHODS: Histological analysis of consecutive periocular BCC specimens. MAIN OUTCOME MEASURES: Date of resection, patient age at resection, gender, tumour location, histological subtype and perineural invasion. RESULTS: From 2006 to 2012, a total of 1713 consecutive periocular BCC excision specimens were analysed. The mean age at resection was 68.8 years (median: 71, range: 21-101). Most specimens (56.4%) were removed from male patients. 52.7% involved the lower eyelid, 29.0% the medial canthus, 10.9% the lateral canthus and 7.5% the upper eyelid. The main histological subtypes identified were nodular (65.7%), infiltrative (17.5%), superficial (12.6%) and micronodular (4.2%). Of the specimens, 25.6% had more than one subtype. The most common subtype combinations were nodular with infiltrative (49.7%), and nodular with superficial (26.0%). CONCLUSIONS: The majority of periocular BCC were located on the lower lid and classified histologically as nodular. Infiltrative BCC occurred more frequently than the superficial subtype. As the proportion of mixed BCC containing aggressive subtypes is high, surgical excision with margin control should be considered for periocular BCC.

Intrastromal Corneal Ring Segment Implantation Followed by Simultaneous Topography-Guided Photorefractive Keratectomy and Corneal Cross-Linking for Contact Lens-Intolerant Keratoconus.

PURPOSE: This study aimed to evaluate the efficacy and safety of Keraring implantation followed by simultaneous topography-guided photorefractive keratectomy (TGPRK) and corneal cross-linking (CXL) in the management of keratoconus. METHODS: This is a single-center, private practice, retrospective review. Patients with keratoconus who were intolerant to contact lens wear underwent implantation of the Keraring, followed by TGPRK with CXL from 2 to 36 months after implantation. Main outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refraction (cylinder and spherical equivalent), keratometry (steep, maximum, and central), and central corneal thickness (CCT). Patients were followed up for 3 to 60 months postoperatively. RESULTS: Fifty-seven eyes from 45 patients were included. The mean time between Keraring and TGPRK/CXL was 6.0 ± 6.0 months. Patients were followed up for a mean of 28.6 ± 20.1 months after Keraring insertion. At 12-month follow-up, there was a statistically significant improvement in mean UDVA (0.94 ± 0.49-0.35 ± 0.23, P < 0.01), CDVA (0.39 ± 0.26-0.17 ± 0.15, P < 0.01), cylinder (-4.97 ± 2.68 to -1.74 ± 1.25, P < 0.01), steep keratometry (51.25 ± 3.37-45.03 ± 2.27, P < 0.01), central keratometry (52.59 ± 4.98-46.99 ± 3.53, P < 0.01), and maximum keratometry (58.78 ± 4.22-50.76 ± 3.42, P < 0.01). These results were sustained at 48-month follow-up. CCT decreased at 12 months after TGPRK (461.84 ± 27.46-418.94 ± 45.62, P < 0.01) and remained stable at 60 months. Postoperatively, 2 eyes (3.51%) had corneal haze, resulting in decrease in CDVA; 1 was treated successfully with repeat PRK; and 1 patient (1.75%) had wound melt due to partial Keraring extrusion, which settled with repositioning. CONCLUSIONS: Keraring implantation followed by simultaneous TGPRK and CXL appears to be effective in the long term in improving UDVA, CDVA, cylinder, CCT, and keratometry in patients with keratoconus who are intolerant to contact lenses.

Impact of Type 2 diabetes mellitus and insulin use on progression to glaucoma surgery in primary open angle glaucoma.

PURPOSE: To investigate outcomes of primary open-angle glaucoma (POAG) patients with and without type 2 diabetes mellitus (T2DM). METHODS: Retrospective observational study using U.S. nationwide healthcare insurance claims database. Patients ≥40 years old with at least one HbA1c within one year of POAG diagnosis were included. Diabetic factors associated with POAG progression requiring glaucoma surgery were evaluated using multivariable Cox proportional hazards regression models adjusted for demographic, diabetic and glaucoma factors. T2DM diagnosis and use of either oral hypoglycaemic agents or insulin therapy were assessed in association with POAG progression requiring glaucoma surgery. RESULTS: 104,515 POAG patients were included, of which 70,315 (67%) had T2DM. The mean age was 68.9 years (Standard deviation 9.2) and 55% were female. Of those with T2DM, 93% were taking medication (65,468); 95% (62,412) taking oral hypoglycaemic agents, and 34% (22,028) were on insulin. In multivariable analyses, patients with T2DM had a higher hazard of requiring glaucoma surgery (Hazard ratio, HR 1.15, 95% CI 1.09-1.21, p < 0.001). Higher mean HbA1c was also a significant predictor of progression requiring glaucoma surgery (HR 1.02, 95% CI 1.01-1.03, p < 0.001). When evaluating only patients who were taking antidiabetic medication, after adjusting for confounders, insulin use was associated with a 1.20 higher hazard of requiring glaucoma surgery compared to oral hypoglycaemic agents (95% CI 1.14-1.27, p < 0.001), but when stratified by HbA1c, this effect was only significant for those with HbA1c > 7.5%. CONCLUSIONS: Higher baseline HbA1c, particularly in patients taking insulin may be associated with higher rates of glaucoma surgery in POAG.