United States

Background
Ophthalmic image quality is impacted by ocular pathology, decreasing accuracy of artificial intelligence (AI) algorithms classifying these images. This study uses AI to improve image quality on color fundus photos (CFPs) to determine if this will restore an AI algorithm’s accuracy in identifying diabetic retinopathy (DR) despite simulated cataracts (SCs).
Methods
A convolutional neural network (CNN) was trained to classify CFPs as either DR or non-DR. Cataracts were simulated by applying Gaussian blur, and the CNN was used to classify these images. A Very Deep Super-Resolution (VDSR) AI was used to enhance the images with simulated cataracts. The CNN then classified these images.
Results
The CNN was able to classify the dataset without any SC with an accuracy of 93%. This accuracy decreased to 78% with SC, but improved back to 85% after images were enhanced using the VDSR.
Conclusion
This study shows that despite AI accuracy decreasing with noise from SC, it can be improved partially using AI-based image enhancement.


AMA Research Challenge 2024 

Image Resolution Enhancement for Improving an Artificial Intelligence Algorithm’s Accuracy in Detecting Diabetic Retinopathy through Simulated Cataract

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Background:
Stent-based MIGS (sb-MIGS) is a revolutionary technology that allows patients to receive sight-saving procedures in a safer and less invasive way. The utilization of sb-MIGS nationally has yet to be explored. Epic Cosmos is a dataset made up of 260-million patients who receive care at a healthcare institution that uses Epic as their electronic health record system. While Sb-MIGS has become popular over the last 10 years, there has been limited published data focused on demographic variations, making our study the first to investigate this topic. 

Method:
The proportion of patients with a diagnosis of mild or moderate primary open-angle glaucoma (mm-POAG), ICD-10 code H40.11X, was compared to the proportion of patients who underwent sb-MIGS, CPT code 0191T denoting iStent or Hydrus implantation, between 1/2014 - 12/2023.

Results:
19149 patients received sb-MIGS out of 361830 mm-POAG patients. Most mm-POAG patients resided in urban areas (90.3% urban vs 6.5% rural; p<0.01). Most sb-MIGS were performed in urban areas (86.4% vs 9.7%; p<0.01). These splits are somewhat different from the urban/rural population split (80/20) per the 2020 US census. A higher proportion of rural patients underwent sb-MIGS relative to mm-POAG rates (~5/100 rural patients vs ~3/100 urban patients; p<0.01), which coincided with an odds ratio of 26.0. Rural non-Hispanic whites (NHW) (90.9% sb-MIGS vs 90% mm-POAG; p=0.34) and minorities, composed of Black-Americans, American-Indian and Hispanic patients, (9.1% vs 9.2%; p=0.88) received sb-MIGS at rates similar to mm-POAG diagnoses rates. Urban NHWs received sb-MIGS at rates significantly higher than mm-POAG diagnosis rates (73.8% vs 63.4%; p<0.01). Urban minorities received sb-MIGS at considerably lower rates versus mm-POAG diagnosis rates (10.9% vs 37.6%; p<0.01). The Epic customer profile limits this study.

Conclusions:
Our findings suggest that mm-POAG diagnoses and sb-MIGS rates are significantly higher in urban areas, where racial and ethnic barriers to sb-MIGS appear to be exacerbated. While geographic barriers may limit rural communities from getting access to eye care, ethnic and racial barriers may not be as limiting.

Insights from a Nationwide Electronic Health Record Cohort on Disparities in Microinvasive Glaucoma Surgery Utilization

Background
Amidst the growing concern over methamphetamine's ophthalmic sequelae, our study focuses on methamphetamine associated keratitis-induced corneal perforation, a significant but underreported complication of methamphetamine use. Three primary mechanisms have been suspected as the link between methamphetamine use and corneal ulcer formation. Firstly, methamphetamine promotes vasoconstriction which in turn leads to corneal stromal neovascularization. Additionally, methamphetamine can cause neurotrophic keratitis which elevates patients’ pain threshold, potentially delaying care. Methamphetamine users also experience hyper-fixation on foreign body sensations which may result in or worsen epithelial defects due to continued physical irritation of the eye. This retrospective chart review aims to illuminate the correlation between methamphetamine use and the development of corneal ulcer perforation treated with therapeutic penetrating keratoplasty (PKP).
Methods
We evaluated 8 patients with a documented history of methamphetamine use who developed corneal ulcers which perforated and subsequently underwent PKP at Loma Linda University Health. The study assessed post-operative outcomes, including best-corrected visual acuity (BCVA), complications, graft survival, and follow-up duration. Furthermore, concomitant drug use and associated microbial infections were also examined.
Results
Our findings underscore the critical impact of methamphetamine use on ocular health, specifically highlighting risk of keratitis leading to corneal perforations. Post-operative outcomes reveal no significant BCVA improvement (p = 0.8323) and poor graft survival rates with an average graft survival time of less than one year. Additionally, the majority of patients had a challenging clinical course with 71.4% of patients demonstrating inconsistent follow-up and 66.7% of patients with at least 6-months of follow-up data experiencing graft failure within one year of their PKP. More than 50% of patients presented with a significant post-operative complication, including corneal edema, epithelial defects, and corneal neovascularization.
Conclusion
Methamphetamine-induced keratitis presents unique clinical challenges, including a risk for corneal perforation and subsequent need for a therapeutic PKP. Our study highlights the importance of recognizing methamphetamine use as a significant risk factor for severe ocular complications and advocating for early detection and multidisciplinary management to optimize outcomes. The findings call for increased awareness and research into targeted interventions that can reduce the adverse ophthalmic effects of methamphetamine abuse.


Methamphetamine Associated Corneal Ulcer Perforation: Poor Post-Operative Outcomes with Penetrating Keratoplasty

Optimizing Ophthalmology Education via ChatBot-Generated Materials: Readability Analysis of AI-generated Patient Education Materials and North American Neuro-Ophthalmology Society (NANOS) Patient Brochures

Background:
It is crucial that patients are offered concise patient education materials (PEMs) to facilitate an enhanced understanding of diagnoses and treatment options. As the average American reads at an 8th grade reading level, the AMA suggests that PEMs be written at a 6th grade level. Despite significant efforts made by NANOS to provide easily accessible webpages for different diagnoses, treatments, and surgeries, the readability of such materials exceeds these recommended guidelines. AI chatbots such as Chat-GPT and Google’s Bard can generate sophisticated responses to free-text input and modifying responses to user feedback. When prompted appropriately, such technology offers promising application to fill the need for more comprehensible ophthalmological PEMs. As such, the aim of this study is to compare the readability of North American Neuro-Ophthalmology Society (NANOS) patient brochures to that of PEMs generated by the AI-chat bots ChatGPT 3.5 and Google Bard.

Methods:
PEMs on 13 common neuro-ophthalmology topics were generated by ChatGPT 3.5 and Google Bard, with and without a 6th grade reading level prompt. The PEMs were analyzed using seven readability metrics: Flesch Reading Ease score, Gunning Fog Index, Flesch-Kincaid Grade Level, Coleman–Liau Index, SMOG Index Score, Automated Readability Index, and Linsear Write Readability Score. Each AI-generated PEM was compared with the equivalent NANOS PEM. 

Results:
When comparing ChatGPT generated PEMs to NANOS brochures, unprompted ChatGPT PEMs consistently had lower readability scores (Flesch-Reading Ease Score NANOS 49.5 ± 3.3; ChatGPT 43.8 ± 8.8, p = 0.04) and higher grade level-equivalent readability scores (SMOG index NANOS 9.7 ± 0.5; ChatGPT 10.4 ± 1.0, p = 0.04), indicating that this material may be the most difficult to comprehend in its unprompted form. On the other hand, Bard generated PEMs that corresponded to a lower grade level compared to NANOS brochures (Linsear-Write Formula NANOS 12.1 ± 1.5; Bard 10.6 ± 2.2), though this difference was non-significant. However, when prompted to produce PEMs at a 6th grade reading level, both ChatGPT and Bard possessed far superior readability scores across all readability metrics compared to NANOS texts. The grade-level equivalent averaged around 8 for both ChatGPT and Google Bard, whereas NANOS brochures corresponded to an 11th grade level.

Conclusion:
This study offers compelling evidence that, when prompted appropriately, AI chat bots can generate comprehensible PEMs for patients on a variety of neuro-ophthalmology topics. Use of this technology in a clinical setting may offer patients with succinct and readable information on complex topics and can guide patient-oriented decision making. Furthermore, use of AI chat bots in this manner may be clinically beneficial in satellite centers where there is a scarcity of neuro-ophthalmologists by assisting triage of patients for neuro-ophthalmology referrals.

Optimizing Ophthalmology Patient Education via ChatBot-Generated Materials: Readability Analysis of AI-generated Patient Education Materials and the North American Neuro-Ophthalmology Society Patient Brochures

Purpose: The role of face-down posturing following rhegmatogenous retinal detachment (RRD) repair remains a consistent management component; however, there is no direct evidence to allow firm conclusions as to what role face-down positioning plays following RRD repair with modern micro-incisional vitrectomy surgery (MIVS) platforms. We evaluated the anatomic and visual outcomes of primary vitrectomy for RRD repair, employing no amount of post-operative prone positioning (POPP) to clarify the role of face-down posturing for RRD re-attachment.

Methods: Retrospective consecutive interventional case series of 116 eyes in 116 patients undergoing primary vitrectomy for RRD repair. Surgical outcomes, single surgery anatomic success (SSAS), and post-operative best-corrected visual acuity (BCVA) were investigated. The primary objective is to study the anatomic and visual outcomes of vitrectomy RRD re-attachment employing no POPP.

Results: SSAS was achieved in 112 (96.5%) of 116 eyes; SSAS was 100% in phakic patients (n=56) and 93% in pseudophakic patients (n=60), with both groups experiencing a mean improvement in BCVA. 

Conclusions: Primary vitrectomy with no POPP is a successful surgical intervention for RRD repair. Our current anatomical closure rate is one of the highest reported in the literature and involved a large number of macula-off RRDs, with minimal complications and significant improvement in BCVA, primarily using 14% C3F8 for gas tamponade.

Outcomes of Primary Vitrectomy for Rhegmatogenous Retinal Detachment: Interventional Retrospective Consecutive Case Series of 116 Patients with no Post-operative Prone Positioning

Background: Retinal diseases such as neovascular age-related macular degeneration (nAMD), diabetic macular edema, and diabetic retinopathy are leading causes of irreversible blindness globally, despite the availability of anti-vascular endothelial growth factor (anti-VEGF) treatments. Current therapeutic protocols involve monthly intraocular injections of anti-VEGF agents, which impose a significant burden on patients and contribute to suboptimal treatment adherence. Genentech’s SUSVIMO, a titanium-based device implanted in the conjunctiva, offers a bi-annual refill schedule, dispensing ranibizumab over six months. However, its usage is associated with risks, including ocular infections, retinal detachment, implant dislocation, and hemorrhage. Our research aims to develop an improved intraocular device made from biocompatible silicone, designed to minimize these adverse effects while ensuring continuous medication delivery. The implantation procedure parallels cataract surgery, positioning the device within the ocular lens capsule. This approach leverages the need for cataract surgery in patients with progressive retinal diseases, allowing simultaneous implantation of the drug delivery device alongside an artificial intraocular lens. The device is refillable every six months, facilitating continuous diffusion of medication to the retina.
Methods: We used the cataract surgery technique to implant our intraocular silicone device into an artificial lens capsule. Three different injector prototypes were tested for device implantation reliability by conducting ten trials for each prototype injector.
Results: Device insertion reliability proved to be more successful using the type-2 injector prototype, due to less likelihood of the device ripping while pressure was applied to eject the device into the lens capsule. 
Conclusion: Our device has the potential to become an efficient intraocular drug delivery system that will benefit patients with progressive retinal diseases that require monthly injections of anti-VEGF. More testing is required in live animal models to determine the device medication diffusion rate and dependability. 


Testing the Reliability of an Intraocular Drug Delivery Device

The Association of Blepharoplasty and Ptosis Repair Surgeries with the Development of Postoperative Dry Eye Syndrome (DES) 

Background
Dry Eye Syndrome (DES) poses a significant ocular health concern globally, leading to pain and visual changes that may persist for several years. This study investigates the incidence and risk factors associated with DES following four different upper eyelid surgeries: Muller's Muscle-Conjunctival Resection (MMCR), internal levator advancement and resection (internal LAR), external levator advancement and resection (external LAR), and Upper-Eyelid Blepharoplasty (UEB). Considering that these surgeries can affect the orbicularis muscle and lacrimal glands, we hypothesized that patients undergoing any of these surgeries could face an increased risk of developing DES post-operation.

Methods
Analyzing the TriNetX patient health database for surgeries conducted between 2003 and 2023, records of 4,551 patients undergoing MMCR, 4,534 patients undergoing internal LAR, 15,326 patients undergoing external LAR, and 27,696 patients undergoing UEB were examined after application of exclusion criteria. Exclusion criteria included ICD-10 codes for pre-existing DES, Meibomian gland dysfunction, Sjogren syndrome, pterygium, thyroid disease, and diabetes. Analysis encompassed linear regression to identify demographic and medical risk factors associated with post-surgical DES. Propensity score matching (PSM) facilitated pairwise outcome comparisons between the four surgeries. 

Results
Internal LAR (OR: 1.17, 95% CI: (1.057,1.296)) and external LAR ((OR: 1.07, 95% CI: (1.008,1.128)) were strongly associated with the development of postoperative DES. Post-PSM pairwise comparison analysis showed that internal LAR carried a greater risk than external LAR (RR = 1.18; 95% CI: (1.062,1.303)). UEB was strongly associated with a decreased risk of postoperative DES ((OR: 0.89, 95% CI: (0.852,0.924)), while MMCR was not significantly associated with postoperative DES (OR: 1.04, 95% CI: (0.939,1.154)). Among all four surgeries, common risk factors for postoperative DES included osteoarthritis (OA), nicotine dependence (ND), obstructive sleep apnea (OSA), and female gender, while Asian ethnicity was a risk factor only for post-UEB DES. 

Conclusion
Internal LAR and external LAR present increased risk for postoperative DES, with OA, ND, OSA, and female gender significantly influencing DES incidence. Notably, internal LAR presents a heightened risk compared to external LAR. These results can offer valuable insights for patients and healthcare providers deliberating on various ptosis repair procedures, emphasizing the critical need for thorough preoperative evaluations and tailored patient education to mitigate the risk of DES in eyelid surgical interventions.


The Association of Blepharoplasty and Ptosis Repair Surgeries with the Development of Postoperative Dry Eye Syndrome (DES)

Background

Anterior cruciate ligament (ACL) reconstruction is a common orthopedic procedure, and patient reported outcome measures (PROMs) are often used to measure long term success of treatment. The study’s goal was to investigate factors associated with clinically meaningful outcomes after ACL reconstruction, as measured by the Patient Acceptable Symptom State (PASS). Additionally, the study aimed to evaluate differences in factors between male and female patients. 


Methods
Patients above the age of 14 who received ACL reconstructions at a single institution were identified retrospectively. Data on demographics, operative notes, and medical history were collected from electronic medical records. These patients were followed up a minimum of two years after surgery with surveys that included an International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form and asked about subsequent diagnoses and surgeries. PASS was defined an IKDC score off 75.9 or higher based on the threshold identified by Muller et al. Univariate logistic regression was performed to identify predictors of achieving PASS, and variables were selected for inclusion in a multivariable logistic regression model based on univariate analysis, prior literature, and clinical relevance. The multivariate regression was stratified by sex. 


Results
A total of 479 patients were included in the study with a mean follow up of 10 ± 5 years. The cohort had an average age of 38 and was 57% female. PASS was achieved by 68% of patients and 9 patients underwent ACL revision surgery. Upon univariate analysis, age, BMI, meniscectomy, revisions and skiing were identified as potential predictors for the multivariable model. Multivariable analysis found that higher BMI (OR 0.95[0.91, 0.99], p = 0.019) and revisions (OR 0.2 [0.04, 0.78], p = 0.025) had independent, negative associations with achievement of PASS. Participation in skiing (OR 1.81 [1.12,2.99], p = 0.018) was found to be positively and independently associated with achieving PASS. Among males, higher BMI (0.9 [0.83, 0.99], p = 0.023) was negatively associated with PASS and participation in skiing (3.52 [1.63, 8.38], p = .002) was positively associated with PASS. Among females, revisions (OR 0.09 [0.00,0.63], p = 0.034) were negatively associated with achievement of PASS. 

Conclusion

Sex differences were observed in factors associated with achieving PASS after ACL reconstruction. Among males, BMI and skiing were found to be associated with PASS, while among females, revision surgery was a significant predictor. These results highlight the need for further investigation of sex specific factors in ACL reconstruction outcomes. 


Sex-specific factors associated with achieving Patient Acceptable Symptom State (PASS) at a mean ten year follow up after anterior cruciate ligament (ACL) reconstruction.

Background
GGS and MCGR are operations aimed to correct and control severe progressive spine deformity while maintaining growth in i-EOS. Past studies yielded similar results between constructs but used vertical coronal measures (e.g. T1-S1), which don’t account for growth outside of plane of measurement due to the spine deformity. This study compares outcomes of GGS and MCGR in i-EOS using 3D-TSL, a validated method that measures spine length in 3D.
Methods
A multi-center database was queried for patients undergoing MCGR / GGS surgery for i-EOS with minimum 2-year follow-up. 31 GGS and 130 MCGR patients were included with measurements at preop, postop, and 2 years. Mixed-model statistics allowed for missing data points and included age group, intervention type, and visit as fixed factors with subject as random. Growth was calculated with paired values; thus growth numbers may not equal change in average values.
Results
There were 161 patients (99 female, 61%) whose mean age at surgery was 8.1 yrs. 19.3% GGS and 8.5% MCGR underwent repeat surgeries within the study period. Age, # of instrumented levels, and preop kyphosis/scoliosis were similar between groups. Total cohort mean scoliosis was 70° preop, 38° postop and 41° at final (p<0.001). GGS reduced the major deformity from 67° to 26° (61 % correction), with a 9° loss of correction at 2 years to 35° (46% correction, p=.02). MCGR reduced the major deformity 71° to 40° (37% correction) but did not significantly lose correction (+2°; final 42°, 34% correction) and was not different from GGS at follow-up. GGS maintained kyphosis perioperatively with increase at 2 years (+8°, p=.004), whereas MCGR decreased at postop (-7°, p<.001) with increase of 6° at final (p=.002). Both groups demonstrated T1-S1 height increase from preop (281 mm) to postop (314 mm) and 2-year (336 mm) (p<.001). 3D-TSL didn’t significantly change perioperatively (338 to 342 mm) for either construct. At 2 years GGS 3D-TSL increased 32.6 mm (16.3 /year), while MCGR increased 27.5 mm (13.8/year) (p=.29).
Conclusion
In i-EOS MCGR and GGS resulted in increase in T1-S1 height preop to postop, but there was no change in 3D-TSL. Postop to Final 3D-TSL identified growth up to 2 years postop in both constructs. T1-S1 height changes suggest that changes in deformity reduce reliability of planar measurements when assessing spine growth. 3D-TSL constitutes a more reliable indicator of spine growth after i-EOS surgery. Overall, GGS and MCGR offer similar outcomes 2 years postop as assessed by 3D- TSL.

3-Dimensional True Spine Length (3D-TSL) In Growth-Guidance Surgery (GGS) vs. Magnetically Controlled Growing Rods (MCGR) for Idiopathic Early Onset Scoliosis (i-EOS)

Background
The “Probable Zone” refers to the area of the hand where the Berrettini Anastomosis (BA) typically occurs. Measuring the dimensions of the BA within the “Probable Zone” is essential for advancing clinical diagnosis, surgical planning, and nerve repair strategies. The BA, an exclusively sensory anastomosis, arises from the communication of common digital nerve three (CDN3) of the median nerve and common digital nerve four (CDN4) of the ulnar nerve near the flexor retinaculum. In previous studies, the prevalence, patterns, and functions of the BA were examined, particularly in carpal tunnel release, where damage to CDN3 can occur. This pilot study expands on the significance of measurements of the BA, delineating the clinical importance of understanding the “Probable Zone.”

Methods
Sample collection was restricted to hands dissected at Tilman J. Fertitta Family College of Medicine and Baylor College of Medicine. With 104 samples, proper identification of the BA required dissection of the median and ulnar nerves' CDN3 and CDN4, and surrounding nerve distributions. Following hand dimension measurements, the determination of the BA allowed for accurate measurement of its dimensions. The hands' lengths were measured from the bistyloid line to the joint of the third digit metacarpophalangeal (MCP), and the width was measured from the second digit MCP to the fifth digit MCP. The BA was measured from its major origin and insertion points. All measurements were collected using a digital caliper.

Results
The BA’s probable zone was calculated using comparative measurements from all reference points. The measured dimensions for the hand size yielded a mean hand length of 79.45 mm and a mean hand width of 68.15 mm. The BA measured a mean length of 22.03 mm (x = 12.34 mm and y = 10.79 mm). The probable zone extends between 36.63% to 50.21% of the hand’s length and between 26.11% to 44.21% of the hand’s width.

Conclusion
This palmar “probable zone” within the hypothenar eminence represents the location where communication patterns are most likely to be found. Previous BA studies have described a similar “reference area” or “risk zone,” although slightly larger than that of the current study. Iatrogenic injury to the BA has been documented in common hand procedures, including carpal tunnel release, ring finger flexor tendon surgery, and Dupuytren’s fasciectomy, reporting symptoms of unpleasant hyperesthesia. Providing precise surface landmarks for clinicians may assist with preoperative preparations to avoid potential BA injury.


A Cadaveric Pilot Study on the 'Probable Zone' of the Berrettini Anastomosis

Background - Multiple autograft choices are available for anterior cruciate ligament reconstruction (ACLR), however the ideal graft choice has not been determined. While there are technical differences, consideration of cost-driving factors that influence ACLR graft choice could help optimize value-based care. This study aims to evaluate the expenses associated with different graft choices for ACLR, considering demographic variables and graft cost. 

Methods – A retrospective chart review was performed from January 2020 to August 2023 for patients undergoing primary ACLR at one health system. All adult patients who have undergone ACL repair surgery within this timeframe were included. Demographic data including sex, age, ethnicity, body mass index (BMI) was collected. Socioeconomic status (SES) was analyzed using median household income (MHI) and area deprivation index (ADI) based on patient addresses (UW-Madison). Graft type and costs were obtained from the electronic medical record. Multiple linear regressions and t-test analyses were performed. 

Results – A total of 389 patients were included with 274 BTB grafts, 64 hamstring grafts, and 51 quad grafts. Mean cost of BTB graft was $3,730.35, hamstring graft was $3,491.43, and quad graft was $4,280.34. Both hamstring and quad grafts were significantly correlated with greater total costs (p=0.018) (p=0.006), while BTB grafts were not (p=0.232). no significant correlations were found between ADI, sex, race, age, insurance type, and smoking and total graft costs. BMI, however, was significantly associated with greater total supply costs (p=0.015). 

Conclusion – Graft selection in ACLR was identified as a modifiable cost driver in this study, with hamstring grafts found to be significantly cheaper and quad grafts significantly more expensive. The average cost is highest when using a quad graft and lowest when using a hamstring graft. BMI also proved to be a contributor to costs in ACLR. 


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