Publications by authors named "Nita Valikodath"

23 Publications

  • Page 1 of 1

Evaluation of Artificial Intelligence-Based Intraoperative Guidance Tools for Phacoemulsification Cataract Surgery.

JAMA Ophthalmol 2022 Jan 13. Epub 2022 Jan 13.

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago.

Importance: Complications that arise from phacoemulsification procedures can lead to worse visual outcomes. Real-time image processing with artificial intelligence tools can extract data to deliver surgical guidance, potentially enhancing the surgical environment.

Objective: To evaluate the ability of a deep neural network to track the pupil, identify the surgical phase, and activate specific computer vision tools to aid the surgeon during phacoemulsification cataract surgery by providing visual feedback in real time.

Design, Setting, And Participants: This cross-sectional study evaluated deidentified surgical videos of phacoemulsification cataract operations performed by faculty and trainee surgeons in a university-based ophthalmology department between July 1, 2020, and January 1, 2021, in a population-based cohort of patients.

Exposures: A region-based convolutional neural network was used to receive frames from the video source and, in real time, locate the pupil and in parallel identify the surgical phase being performed. Computer vision-based algorithms were applied according to the phase identified, providing visual feedback to the surgeon.

Main Outcomes And Measures: Outcomes were area under the receiver operator characteristic curve and area under the precision-recall curve for surgical phase classification and Dice score (harmonic mean of the precision and recall [sensitivity]) for detection of the pupil boundary. Network performance was assessed as video output in frames per second. A usability survey was administered to volunteer cataract surgeons previously unfamiliar with the platform.

Results: The region-based convolutional neural network model achieved area under the receiver operating characteristic curve values of 0.996 for capsulorhexis, 0.972 for phacoemulsification, 0.997 for cortex removal, and 0.880 for idle phase recognition. The final algorithm reached a Dice score of 90.23% for pupil segmentation and a mean (SD) processing speed of 97 (34) frames per second. Among the 11 cataract surgeons surveyed, 8 (72%) were mostly or extremely likely to use the current platform during surgery for complex cataract.

Conclusions And Relevance: A computer vision approach using deep neural networks was able to pupil track, identify the surgical phase being executed, and activate surgical guidance tools. These results suggest that an artificial intelligence-based surgical guidance platform has the potential to enhance the surgeon experience in phacoemulsification cataract surgery. This proof-of-concept investigation suggests that a pipeline from a surgical microscope could be integrated with neural networks and computer vision tools to provide surgical guidance in real time.
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http://dx.doi.org/10.1001/jamaophthalmol.2021.5742DOI Listing
January 2022

Assessment and management of retinopathy of prematurity in the era of anti-vascular endothelial growth factor (VEGF).

Prog Retin Eye Res 2021 Nov 9:101018. Epub 2021 Nov 9.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan. Electronic address:

The incidence of retinopathy of prematurity (ROP) continues to rise due to the improved survival of very low birth weight infants in developed countries. This epidemic is also fueled by increased survival of preterm babies with variable use of oxygen and a lack of ROP awareness and screening services in resource-limited regions. Improvements in technology and a basic understanding of the disease pathophysiology have changed the way we screen and manage ROP, educate providers and patients, and improve ROP awareness. Advancements in imaging techniques, expansion of telemedicine services, and the potential for artificial intelligence-assisted ROP screening programs have created opportunities to improve ROP care in areas with a shortage of ophthalmologists trained in ROP. To address the gap in provider knowledge regarding ROP, the Global Education Network for Retinopathy of Prematurity (GEN-ROP) created a web-based tele-education training module that can be used to educate all providers involved in ROP, including non-physician ROP screeners. Over the past 50 years, the treatment of severe ROP has evolved from limited treatment modalities to cryotherapy and laser photocoagulation. More recently, there has been growing evidence to support the use of anti-vascular endothelial growth factor (VEGF) agents for the treatment of severe ROP. However, VEGF is known to be important in organogenesis and microvascular maintenance, and given that intravitreal anti-VEGF treatment can result in systemic VEGF suppression over a period of at least 1-12 weeks, there are concerns regarding adverse effects and long-term ocular and systemic developmental consequences of anti-VEGF therapy. Future research in ophthalmology to address the growing burden of ROP should focus on cost-effective fundus imaging devices, implementation of artificial intelligence platforms, updated treatment algorithms with optimal use of anti-VEGF and careful investigation of its long-term effects, and surgical options in advanced ROP. Addressing these unmet needs will aid the global effort against the ROP epidemic and optimize our understanding and treatment of this blinding disease.
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http://dx.doi.org/10.1016/j.preteyeres.2021.101018DOI Listing
November 2021

Assessment of a novel ophthalmology tele-triage system during the COVID-19 pandemic.

BMC Ophthalmol 2021 Sep 24;21(1):346. Epub 2021 Sep 24.

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL, 60612, USA.

Background: In response to the COVID-19 pandemic, a web-based tele-triage system was created to prioritize in-person clinic visits and ensure safety at the University of Illinois at Chicago Department of Ophthalmology and Visual Sciences during a statewide shelter-in-place order. The aim of this study is to evaluate the impact of the tele-triage system on urgent visit volume and explore the characteristics of acute visit requests at a tertiary referral eye center.

Methods: This retrospective study analyzed acute visit requests between April 6, 2020 and June 6, 2020. Descriptive statistics, chi-square tests, ANOVA, and bivariate logistic regression were used to compare variables with a p-value of 0.05.

Results: Three hundred fifty-eight surveys were completed. Mean age was 49.7 ± 18.8 years (range 2-91). The majority of requests were determined as urgent (63.0%) or emergent (0.8%). Forty-nine patients had recent eye trauma (13.7%), and the most common reported symptoms were new onset eye pain (25.7%) and photophobia (22.9%). Most patients were self-referred (63.7%), though provider referral was more common in patients with symptoms of new onset lid swelling (p < 0.01), diplopia (p < 0.01), flashing lights (p = 0.02), or droopy eyelid (p < 0.01). Patients presenting with symptom onset within 48 h tended to be younger (45.8 years) versus those with symptom duration of 48 h to 1 week (49.6 years), or more than 1 week (52.6 years; p < 0.01).

Conclusion: This novel tele-triage system screened out one-third of acute visit requests as non-urgent, which limited in-person visits during the initial shelter-in-place period of the pandemic. Tele-triage systems should be implemented in eye care practices for future emergency preparedness.
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http://dx.doi.org/10.1186/s12886-021-02112-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8461141PMC
September 2021

Description and management of retinopathy of prematurity reactivation after intravitreal antivascular endothelial growth factor therapy.

Curr Opin Ophthalmol 2021 Sep;32(5):468-474

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois.

Purpose Of Review: To review the literature regarding reactivation of retinopathy of prematurity (ROP) after treatment with antivascular endothelial growth factor (anti-VEGF) agents.

Recent Findings: Reactivation can occur after anti-VEGF or laser. Risk factors for reactivation include patient and disease-related factors. Various studies are evaluating the use of different anti-VEGF agents and reactivation rates. However, the definition of reactivation varies between studies.

Summary: The literature has varied definitions of reactivation, which is often used interchangeably with recurrence. It is important to recognize features of reactivation of ROP to appropriately manage patients and conduct clinical trials. The International Classification of ROP 3rd edition has established a consensus guideline regarding terminology describing reactivation.
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http://dx.doi.org/10.1097/ICU.0000000000000786DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8514167PMC
September 2021

Odontogenic Subperiosteal Abscess of the Lateral Orbit: Timely Recognition and Management.

Eur J Dent 2021 Oct 13;15(4):802-805. Epub 2021 Aug 13.

Chicago Medical Center, The University of Illinois, Chicago, Illinois, United States.

Orbital abscess is a rare entity due to an odontogenic infection. The progression from a toothache to serious complications such as blindness or death can be sudden and severe. The authors present the case of a 13-year-old male patient with a 2-day history of dental pain, which progressed to involve the periorbital tissues. He was experiencing visual symptoms. Computed tomographic imaging revealed a canine space abscess associated with a carious right maxillary molar in continuity with a subperiosteal abscess of the right lateral orbit. Surgical drainage was performed under general anesthesia via intraoral and extraoral approaches. The postoperative course was uncomplicated and vision improved. Multidisciplinary and timely management is crucial for successful outcomes in managing orbital abscesses of odontogenic origin. Therefore, it is crucial for emergency and primary care physicians to recognize when specialist consultation is indicated and expedite this process.
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http://dx.doi.org/10.1055/s-0041-1731588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8630978PMC
October 2021

Addressing the Third Epidemic of Retinopathy of Prematurity Through Telemedicine and Technology: A Systematic Review.

J Pediatr Ophthalmol Strabismus 2021 Jul-Aug;58(4):261-269. Epub 2021 Jul 1.

The rising prevalence of retinopathy of prematurity (ROP) in low- and middle-income countries has increased the need for screening at-risk infants. The purpose of this article was to review the impact of tele-medicine and technology on ROP screening programs. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed using PubMed, Pro-Quest, and Google Scholar bibliographic search engine. Terms searched included retinopathy of prematurity, telemedicine, and tele-ophthalmology. Data regarding internet access and gross domestic product per capita were obtained from the World Bank. Information was also obtained about internet access, speeds, and costs in low-income countries. There has been increasing integration of telemedicine and technology for ROP screening and management. Low-income countries are using available internet options and information and communications technology for ROP screening, which can aid in addressing the unique challenges faced by low-income countries. This provides a promising solution to the third epidemic of ROP by expanding and improving screening and management. Although telemedicine systems may serve as a cost-effective approach to facilitate delivery of health care, programs (especially in lowand middle-income countries) require national support to maintain its infrastructure. .
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http://dx.doi.org/10.3928/01913913-20210223-01DOI Listing
November 2021

Impact of Artificial Intelligence on Medical Education in Ophthalmology.

Transl Vis Sci Technol 2021 06;10(7):14

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA.

Clinical care in ophthalmology is rapidly evolving as artificial intelligence (AI) algorithms are being developed. The medical community and national and federal regulatory bodies are recognizing the importance of adapting to AI. However, there is a gap in physicians' understanding of AI and its implications regarding its potential use in clinical care, and there are limited resources and established programs focused on AI and medical education in ophthalmology. Physicians are essential in the application of AI in a clinical context. An AI curriculum in ophthalmology can help provide physicians with a fund of knowledge and skills to integrate AI into their practice. In this paper, we provide general recommendations for an AI curriculum for medical students, residents, and fellows in ophthalmology.
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http://dx.doi.org/10.1167/tvst.10.7.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8212436PMC
June 2021

Evaluation of pediatric ophthalmologists' perspectives of artificial intelligence in ophthalmology.

J AAPOS 2021 06 1;25(3):164.e1-164.e5. Epub 2021 Jun 1.

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois. Electronic address:

Purpose: To survey pediatric ophthalmologists on their perspectives of artificial intelligence (AI) in ophthalmology.

Methods: This is a subgroup analysis of a study previously reported. In March 2019, members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) were recruited via the online AAPOS discussion board to voluntarily complete a Web-based survey consisting of 15 items. Survey items assessed the extent participants "agreed" or "disagreed" with statements on the perceived benefits and concerns of AI in ophthalmology. Responses were analyzed using descriptive statistics.

Results: A total of 80 pediatric ophthalmologists who are members of AAPOS completed the survey. The mean number of years since graduating residency was 21 years (range, 0-46). Overall, 91% (73/80) reported understanding the concept of AI, 70% (56/80) believed AI will improve the practice of ophthalmology, 68% (54/80) reported willingness to incorporate AI into their clinical practice, 65% (52/80) did not believe AI will replace physicians, and 71% (57/80) believed AI should be incorporated into medical school and residency curricula. However, 15% (12/80) were concerned that AI will replace physicians, 26% (21/80) believed AI will harm the patient-physician relationship, and 46% (37/80) reported concern over the diagnostic accuracy of AI.

Conclusions: Most pediatric ophthalmologists in this survey viewed the role of AI in ophthalmology positively.
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http://dx.doi.org/10.1016/j.jaapos.2021.01.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328946PMC
June 2021

Bilateral Macular Schisis in a Woman.

JAMA Ophthalmol 2021 Aug;139(8):906-907

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago.

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http://dx.doi.org/10.1001/jamaophthalmol.2020.5292DOI Listing
August 2021

Applications of Artificial Intelligence for Retinopathy of Prematurity Screening.

Pediatrics 2021 03;147(3)

Athinoula A. Martinos Center for Biomedical Imaging and Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts.

Objectives: Childhood blindness from retinopathy of prematurity (ROP) is increasing as a result of improvements in neonatal care worldwide. We evaluate the effectiveness of artificial intelligence (AI)-based screening in an Indian ROP telemedicine program and whether differences in ROP severity between neonatal care units (NCUs) identified by using AI are related to differences in oxygen-titrating capability.

Methods: External validation study of an existing AI-based quantitative severity scale for ROP on a data set of images from the Retinopathy of Prematurity Eradication Save Our Sight ROP telemedicine program in India. All images were assigned an ROP severity score (1-9) by using the Imaging and Informatics in Retinopathy of Prematurity Deep Learning system. We calculated the area under the receiver operating characteristic curve and sensitivity and specificity for treatment-requiring retinopathy of prematurity. Using multivariable linear regression, we evaluated the mean and median ROP severity in each NCU as a function of mean birth weight, gestational age, and the presence of oxygen blenders and pulse oxygenation monitors.

Results: The area under the receiver operating characteristic curve for detection of treatment-requiring retinopathy of prematurity was 0.98, with 100% sensitivity and 78% specificity. We found higher median (interquartile range) ROP severity in NCUs without oxygen blenders and pulse oxygenation monitors, most apparent in bigger infants (>1500 g and 31 weeks' gestation: 2.7 [2.5-3.0] vs 3.1 [2.4-3.8]; = .007, with adjustment for birth weight and gestational age).

Conclusions: Integration of AI into ROP screening programs may lead to improved access to care for secondary prevention of ROP and may facilitate assessment of disease epidemiology and NCU resources.
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http://dx.doi.org/10.1542/peds.2020-016618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7924138PMC
March 2021

Deep Learning for the Diagnosis of Stage in Retinopathy of Prematurity: Accuracy and Generalizability across Populations and Cameras.

Ophthalmol Retina 2021 10 6;5(10):1027-1035. Epub 2021 Feb 6.

Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon. Electronic address:

Purpose: Stage is an important feature to identify in retinal images of infants at risk of retinopathy of prematurity (ROP). The purpose of this study was to implement a convolutional neural network (CNN) for binary detection of stages 1, 2, and 3 in ROP and to evaluate its generalizability across different populations and camera systems.

Design: Diagnostic validation study of CNN for stage detection.

Participants: Retinal fundus images obtained from preterm infants during routine ROP screenings.

Methods: Two datasets were used: 5943 fundus images obtained by RetCam camera (Natus Medical, Pleasanton, CA) from 9 North American institutions and 5049 images obtained by 3nethra camera (Forus Health Incorporated, Bengaluru, India) from 4 hospitals in Nepal. Images were labeled based on the presence of stage by 1 to 3 expert graders. Three CNN models were trained using 5-fold cross-validation on datasets from North America alone, Nepal alone, and a combined dataset and were evaluated on 2 held-out test sets consisting of 708 and 247 images from the Nepali and North American datasets, respectively.

Main Outcome Measures: Convolutional neural network performance was evaluated using area under the receiver operating characteristic curve (AUROC), area under the precision-recall curve (AUPRC), sensitivity, and specificity.

Results: Both the North American- and Nepali-trained models demonstrated high performance on a test set from the same population: AUROC, 0.99; AUPRC, 0.98; sensitivity, 94%; and AUROC, 0.97; AUPRC, 0.91; and sensitivity, 73%; respectively. However, the performance of each model decreased to AUROC of 0.96 and AUPRC of 0.88 (sensitivity, 52%) and AUROC of 0.62 and AUPRC of 0.36 (sensitivity, 44%) when evaluated on a test set from the other population. Compared with the models trained on individual datasets, the model trained on a combined dataset achieved improved performance on each respective test set: sensitivity improved from 94% to 98% on the North American test set and from 73% to 82% on the Nepali test set.

Conclusions: A CNN can identify accurately the presence of ROP stage in retinal images, but performance depends on the similarity between training and testing populations. We demonstrated that internal and external performance can be improved by increasing the heterogeneity of the training dataset features of the training dataset, in this case by combining images from different populations and cameras.
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http://dx.doi.org/10.1016/j.oret.2020.12.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8364291PMC
October 2021

Development of Screening Criteria for Retinopathy of Prematurity in Ulaanbaatar, Mongolia, Using a Web-based Data Management System.

J Pediatr Ophthalmol Strabismus 2020 Sep;57(5):333-339

Purpose: To describe a process for identifying birth weight (BW) and gestational age (GA) screening guidelines in Mongolia.

Methods: This was a prospective cohort study in a tertiary care hospital in Ulaanbataar, Mongolia, of 193 premature infants with GA of 36 weeks or younger and/or BW of 2,000 g or less) with regression analysis to determine associations between BW and GA and the development of retinopathy of prematurity (ROP).

Results: As BW and GA decreased, the relative risk of developing ROP increased. The relative risk of developing any stage of ROP in infants born at 29 weeks or younger was 2.91 (95% CI: 1.55 to 5.44; P < .001] compared to older infants. The relative risk of developing any type of ROP in infants with BW of less than 1,200 g was 2.41 (95% CI: 1.35 to 4.29; P = .003] and developing type 2 or worse ROP was 2.05 (95% CI: 0.99 to 4.25; P = .05).

Conclusions: Infants in Mongolia with heavier BW and older GA who fall outside of current United States screening guidelines of GA of 30 weeks or younger and/or BW of 1,500 g or less developed clinically relevant ROP. [J Pediatr Ophthalmol Strabismus. 2020;57(5):333-339.].
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http://dx.doi.org/10.3928/01913913-20200804-01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880618PMC
September 2020

Posterior tractional membranes following anti-vascular endothelial growth factor for retinopathy of prematurity.

Retin Cases Brief Rep 2020 Jul 15. Epub 2020 Jul 15.

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL.

Purpose: To report two cases of tractional membrane formation following treatment with anti-vascular endothelial growth factor therapy in infants with stage 3 retinopathy of prematurity.

Methods: Retrospective review of electronic medical record for historical information, clinical exam documentation, and imaging from fundus photography, retinal ultrasonography and fluorescein angiography.

Patients: Two patients with stage 3 retinopathy of prematurity, previously treated with laser therapy and intravitreal bevacizumab, were referred to our institution for tractional membranes. The first case is of a male infant with zone II disease that progressed to stage 4A with evidence of inferotemporal tractional retinal detachment only in the left eye. The second case is of a male infant with stable zone I disease with an epiretinal membrane in the left eye.

Results: Pars plicata vitrectomy and membranectomy were required for both cases due to concern for subsequent tractional retinal detachment.

Conclusion: Formation of tractional retinal membranes has been associated with anti-vascular endothelial growth factor therapy. These cases describe the formation of posterior tractional membranes after anti-vascular endothelial growth factor therapy. This potential ocular outcome should be considered when determining treatment plans for retinopathy of prematurity.
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http://dx.doi.org/10.1097/ICB.0000000000001036DOI Listing
July 2020

Evaluation of Potential Systemic Adverse Events Related to Fluorescein Angiography in Pediatric Patients.

Ophthalmol Retina 2020 06 16;4(6):595-601. Epub 2019 Dec 16.

Department of Ophthalmology, Weill Cornell Medical College, New York, New York; Department of Ophthalmology & Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois. Electronic address:

Purpose: To evaluate adverse events of fluorescein angiography (FA) in pediatric patients.

Design: Single-institution retrospective chart review.

Participants: Patients 0 to 18 years of age who underwent FA between January 2010 and December 2015 at a single institution in the United States.

Methods: Pediatric patients who underwent FA by 3 surgeons were included in the study. Patients with fewer than 24 hours of documented follow-up were excluded. Significant adverse events within 24 hours of FA were evaluated. Detailed intraoperative and perioperative physiological parameters, including heart rate, blood pressure, oxygen saturation, and ventilation parameters, in inpatients undergoing simultaneous examination under anesthesia were reviewed. Peri-injection effects of FA were evaluated by 2-tailed paired t test comparison of mean 5-minute preinjection and 5-minute postinjection physiological data.

Main Outcome Measures: Significant adverse events associated with FA.

Results: One hundred fifteen patients with a total of 214 FA examinations were included. No significant adverse events were associated directly with FA. Comparison of mean 5-minute preinjection and postinjection physiologic parameters in 27 patients who underwent intravenous FA during EUA did not reveal significant changes associated with FA. A significant difference was found in average patient age between inpatient (2.5 years) and outpatient (10.7 years) FA (P < 0.00001). The youngest patients who underwent successful FA were 3.8 years old in the outpatient setting and 32 weeks' postmenstrual age in the inpatient setting. Patients younger than 3.8 years accounted for most (77.6%; n = 85) inpatient FA examinations. Excluding patients with a need or likely need for laser or surgery, the reasons for inpatient FA in patients older than 3.8 years included the lack of availability of outpatient ultra-widefield FA (UWFA) and more challenging situations in patients with developmental delay.

Conclusions: Fluorescein angiography was not found to be associated directly with systemic adverse events in pediatric patients in this study. Younger patients more commonly were found to require an inpatient FA, whereas older patients older than 4 years underwent outpatient UWFA.
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http://dx.doi.org/10.1016/j.oret.2019.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880605PMC
June 2020

Ocular features of Townes-Brocks syndrome.

J AAPOS 2020 04 23;24(2):115-118. Epub 2020 Jan 23.

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois. Electronic address:

Townes-Brocks syndrome (TBS) is a rare genetic syndrome associated with heterozygous mutations in SALL1 and characterized by abnormalities of the anus, ear, and thumb. Ophthalmic findings have been rarely reported and include congenital cataract, microphthalmia, optic nerve atrophy, coloboma, epibulbar dermoid, and dysinnervation patterns, such as Duane syndrome and gustatory lacrimation. We report a case of genetically confirmed TBS showing a spectrum of ocular anomalous innervations, including bilateral type 1 Duane syndrome and Möbius sequence, left-sided Marcus Gunn jaw winking, left eye gustatory lacrimation, and lack of emotional tearing bilaterally. Magnetic resonance imaging of brain and orbit showed absence of the abducens nerve bilaterally and of the left facial nerve.
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http://dx.doi.org/10.1016/j.jaapos.2019.12.004DOI Listing
April 2020

Accuracy of a Smartphone-based Autorefractor Compared with Criterion-standard Refraction.

Optom Vis Sci 2018 12;95(12):1135-1141

Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan.

Significance: Uncorrected refractive error is a prevalent problem throughout the world especially among the low-income population who have limited access to professional eye care and cannot afford eyeglasses.

Purpose: The purpose of this study was to evaluate the accuracy and usability of a low-cost, portable, smartphone-based autorefractor (Netra, EyeNetra Inc., Somerville, MA) in adults.

Methods: A cross-sectional study was conducted to compare the portable refractor with subjective (manifest and cycloplegic) refraction for sequential adult participants with best-corrected visual acuity of 20/40 or greater. For each method of refraction, the spherical equivalent was calculated. Differences between methods were tested with linear mixed regression models. A validated usability questionnaire was administered regarding ease of use (100-point scale, higher scores better) for the portable autorefractor.

Results: Eighty-seven subjects (152 eyes) were studied (age range, 20 to 90 years; mean ± standard deviation, 51.9 ± 18.3 years). Mean spherical equivalent by the portable device was -2.76 D (range, -14.75 to 3.63 D) compared with -2.49 D (range, -15.25 to 4.25 D) by manifest refraction. The mean relative difference in spherical equivalent between methods was -0.27 D (P = .001, significantly different than 0 D). The mean absolute difference between methods was 0.69 D (P < .001, significantly different than 0.5-D absolute difference). Similar results were found when comparing spherical equivalent between Netra and cycloplegic refraction methods. Subjects reported average ease of use for the Netra of 75.4 ± 19.8.

Conclusions: The portable autorefractor had small but clinically significant differences from subjective refraction. The device's scores on the usability scale indicate good overall patient acceptance. The device may be valuable for use where there is limited access to a trained refractionist.
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http://dx.doi.org/10.1097/OPX.0000000000001308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6475906PMC
December 2018

Novel Image-Based Analysis for Reduction of Clinician-Dependent Variability in Measurement of the Corneal Ulcer Size.

Cornea 2018 Mar;37(3):331-339

Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, MI.

Purpose: To assess variability in corneal ulcer measurements between ophthalmologists and reduce clinician-dependent variability using semiautomated segmentation of the ulcer from photographs.

Methods: Three ophthalmologists measured 50 patients' eyes for epithelial defects (EDs) and the stromal infiltrate (SI) size using slit-lamp (SL) calipers. SL photographs were obtained. An algorithm was developed for semiautomatic segmenting of the ED and SI in the photographs. Semiautomatic segmentation was repeated 3 times by different users (2 ophthalmologists and 1 trainee). Clinically significant variability was assessed with intraclass correlation coefficients (ICCs) and the percentage of pairwise measurements differing by ≥0.5 mm. Semiautomatic segmentation measurements were compared with manual delineation of the image by a corneal specialist (gold standard) using Dice similarity coefficients.

Results: Ophthalmologists' reliability in measurements by SL calipers had an ICC from 0.84 to 0.88 between examiners. Measurements by semiautomatic segmentation had an ICC from 0.96 to 0.98. SL measures of ulcers by clinical versus semiautomatic segmentation measures differed by ≥0.5 mm in 24% to 38% versus 8% to 28% (ED height); 30% to 52% versus 12% to 34% (ED width); 26% to 38% versus 10% to 32% (SI height); and 38% to 58% versus 14% to 34% (SI width), respectively. Average Dice similarity coefficients between manual and repeated semiautomatic segmentation ranged from 0.83 to 0.86 for the ED and 0.78 to 0.83 for the SI.

Conclusions: Variability exists when measuring corneal ulcers, even among ophthalmologists. Photography and computerized methods for quantifying the ulcer size could reduce variability while remaining accurate and impact quantitative measurement endpoints.
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http://dx.doi.org/10.1097/ICO.0000000000001488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5799030PMC
March 2018

Eye Symptom Questionnaire to Evaluate Anterior Eye Health.

Eye Contact Lens 2018 Nov;44(6):384-389

Department of Ophthalmology and Visual Sciences (M.A.W., N.G.V., P.A.N.-C., L.M.N., D.C.M., P.P.L.), University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation (M.A.W., P.A.N.-C., D.C.M., P.P.L.), University of Michigan, Ann Arbor, MI; and Department of Epidemiology (D.C.M.), University of Michigan School of Public Health, Ann Arbor, MI.

Objectives: Ophthalmologists assess eye complaints with a careful history and eye examination; however, other types of physicians have limited tools to evaluate anterior segment (AS) eye diseases. We identified the eye symptom questions that providers should ask to help determine the presence and urgency of AS eye diseases.

Methods: Persons with and without AS disease completed a self-report eye symptom questionnaire (ESQ) based on the National Institutes of Health Toolbox symptom items in an academic center's corneal and comprehensive eye clinics. Gold standard ophthalmic examination determined the presence and urgency of AS disease. The association between reported symptom severity and the probability of AS disease, or urgent AS disease, was evaluated using logistic regression models, and sensitivity and specificity of the ESQ were also calculated.

Results: A total of 324 eyes of 162 subjects were included in the study. Of these, AS disease was present in 255 eyes (79%); of which, 111 eyes showed urgent disease. Increasing symptom severity for eye pain (odds ratio [OR]=2.58; P<0.001), glare (OR=2.61; P=0.001), and blurry vision (OR=1.98; P<0.001) were associated with increased odds of AS disease. Increasing symptom severity for eye pain (OR=2.02; P<0.001), eye redness (OR=1.69; P=0.02), and blurry vision (OR=1.41, P=0.01) were associated with increased odds of urgent AS disease. For the primary analysis with mild symptoms considered relevant, the sensitivity of the ESQ to detect AS disease was 83% and to detect urgent AS disease was 92%.

Conclusion: Symptoms of eye pain, glare, redness, and blurry vision indicate the presence and urgency of AS disease.
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http://dx.doi.org/10.1097/ICL.0000000000000403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730507PMC
November 2018

Precision of Epithelial Defect Measurements.

Cornea 2017 Apr;36(4):419-424

Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI.

Purpose: To ensure optimal care of patients, cornea specialists measure corneal features, including epithelial defects (ED), with slit-lamp calipers. However, caliper measurements are subject to interphysician variability. We examined the extent of variability in ED measurements between cornea specialists and discuss the potential clinical impact.

Methods: A total of 48 variably sized EDs were created in pig eyes. Three cornea specialists measured the maximum vertical and horizontal ED lengths to the nearest 10th of a millimeter using slit-lamp microscopy. An absolute difference in ED measurement between cornea specialists of 0.5 mm was chosen to be the a priori threshold for clinical significance and was evaluated by the Wilcoxon signed-rank test. Interrater reliability was assessed by intraclass correlation coefficients.

Results: The average absolute difference in the vertical ED length between pairs of examiners ranged from 0.54 to 0.63 mm, and that of the horizontal ED length ranged from 0.44 to 0.46 mm. These differences in ED measurement were not significantly different from 0.5 mm (all P > 0.06). However, pairs of examiners differed in vertical ED length measurements by >0.5 mm in 44% to 52% of EDs and by >1.0 mm in 13% to 17% of EDs. Pairs of examiners differed in horizontal ED length measurements by >0.5 mm in 31% to 40% of EDs and by >1.0 mm in 10% to 15% of EDs. The intraclass correlation coefficient was 0.85 (95% confidence interval, 0.77-0.91) for vertical and 0.84 (95% confidence interval, 0.74-0.90) for horizontal ED measurements.

Conclusions: Cornea specialists showed good reliability in the measured EDs; however, depending on the threshold for clinical significance, a nontrivial percentage of cases have high interexaminer clinical variability.
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http://dx.doi.org/10.1097/ICO.0000000000001148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5517027PMC
April 2017

Agreement of Ocular Symptom Reporting Between Patient-Reported Outcomes and Medical Records.

JAMA Ophthalmol 2017 Mar;135(3):225-231

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Accurate documentation of patient symptoms in the electronic medical record (EMR) is important for high-quality patient care.

Objective: To explore inconsistencies between patient self-report on an Eye Symptom Questionnaire (ESQ) and documentation in the EMR.

Design, Setting, And Participants: This investigation was an observational study in comprehensive ophthalmology and cornea clinics at an academic institution among a convenience sample of 192 consecutive eligible patients, of whom 30 declined participation. Patients were recruited at the Kellogg Eye Center from October 1, 2015, to January 31, 2016. Patients were eligible to be included in the study if they were 18 years or older.

Main Outcomes And Measures: Concordance of symptoms reported on an ESQ with data recorded in the EMR. Agreement of symptom report was analyzed using κ statistics and McNemar tests. Disagreement was defined as a negative symptom report or no mention of a symptom in the EMR for patients who reported moderate to severe symptoms on the ESQ. Logistic regression was used to investigate if patient factors, physician characteristics, or diagnoses were associated with the probability of disagreement for symptoms of blurry vision, pain or discomfort, and redness.

Results: A total of 162 patients (324 eyes) were included. The mean (SD) age of participants was 56.6 (19.4) years, 62.3% (101 of 162) were female, and 84.9% (135 of 159) were white. At the participant level, 33.8% (54 of 160) had discordant reporting of blurry vision between the ESQ and EMR. Likewise, documentation was discordant for reporting glare (48.1% [78 of 162]), pain or discomfort (26.5% [43 of 162]), and redness (24.7% [40 of 162]), with poor to fair agreement (κ range, -0.02 to 0.42). Discordance of symptom reporting was more frequently characterized by positive reporting on the ESQ and lack of documentation in the EMR (Holm-adjusted McNemar P < .03 for 7 of 8 symptoms except for blurry vision [P = .59]). Return visits at which the patient reported blurry vision on the ESQ had increased odds of not reporting the symptom in the EMR compared with new visits (odds ratio, 5.25; 95% CI, 1.69-16.30; Holm-adjusted P = .045).

Conclusions And Relevance: Symptom reporting was inconsistent between patient self-report on an ESQ and documentation in the EMR, with symptoms more frequently recorded on a questionnaire. These results suggest that documentation of symptoms based on EMR data may not provide a comprehensive resource for clinical practice or "big data" research.
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http://dx.doi.org/10.1001/jamaophthalmol.2016.5551DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5404734PMC
March 2017

Impact of a Dedicated Research Rotation during Ophthalmology Residency.

J Acad Ophthalmol 2017 Jan;9(1):e1-e6

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, W. K. Kellogg Eye Center, Ann Arbor, Michigan.

Background: The Accreditation Council for Graduate Medical Education (ACGME) requires that ophthalmology residents participate in scholarly activity during residency. However, residents lack protected time for research.

Objective: To determine the impact of a dedicated research rotation on scholarly productivity and research experience during residency.

Methods: This cohort study compared two groups of ophthalmology residents. Residents who graduated between 2004-2009 did not have dedicated research time and served as control residents (CR) while residents who graduated between 2010-2015 had a dedicated research rotation and served as the intervention group (research residents, RR). Primary outcomes included publications and presentations recorded over a four-year period, spanning the three years of residency and first year after graduation. These were analyzed by linear regression and t-tests. Residents also took surveys regarding research experience and chi squared tests and logistic regression were used to compare these results.

Results: The RR had 0.97 more publications and 1.3 more presentations compared to the CR after adjusting for PhD status, pre-residency publications and presentations, age at graduation, gender and race (p=0.09 and p=0.02, respectively). RR had higher odds of reporting adequate time to complete research (OR=13.11, 95% CI 3.58-48.03, p < 0.001) and satisfaction with their research experience (OR=6.96, 95% CI=2.104-23.053, p=0.002).

Conclusions: Residents with a research rotation had more time to complete research, were more satisfied with their research experience, and generated more publications and presentations compared to residents without the research rotation. A research rotation can help meet ACGME requirements and help residents achieve greater scholarly activity.
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http://dx.doi.org/10.1055/s-0037-1599078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6190916PMC
January 2017

Patient Attitudes Toward Telemedicine for Diabetic Retinopathy.

Telemed J E Health 2017 03 23;23(3):205-212. Epub 2016 Jun 23.

1 Department of Ophthalmology and Visual Sciences, University of Michigan Medical School , Ann Arbor, Michigan.

Introduction: Diabetic retinopathy (DR) is the leading cause of new-onset blindness in adults. Telemedicine is a validated, cost-effective method to improve monitoring. However, little is known of patients' attitudes toward telemedicine for DR. Our study explores factors that influence patients' attitudes toward participating in telemedicine.

Materials And Methods: Ninety seven participants in a university and the Veterans Administration setting completed a survey. Only people with diabetes mellitus (DM) were included. The main outcome was willingness to participate in telemedicine. The other outcomes were perceived convenience and impact on the patient-physician relationship. Participants reported demographic information, comorbidities, and access to healthcare. Analysis was performed with t-tests and multivariable logistic regression.

Results: Demographic factors were not associated with the outcomes (all p > 0.05). Patients had decreased odds of willingness if they valued the patient-physician relationship (adjusted odds ratio [OR] = 0.08, confidence interval [CI] = 0.02-0.35, p = 0.001) or had a longer duration of diabetes (adjusted OR = 0.93, CI = 0.88-0.99, p = 0.02). Patients had increased odds of willingness if they perceived increased convenience (adjusted OR = 8.10, CI = 1.77-36.97, p = 0.01) or had more systemic comorbidities (adjusted OR = 1.85, CI = 1.10-3.11, p = 0.02).

Discussion: It is critical to understand the attitudes of people with DM where telemedicine shows promise for disease management and end-organ damage prevention. Patients' attitudes are influenced by their health and perceptions, but not by their demographics. Receptive patients focus on convenience, whereas unreceptive patients strongly value their patient-physician relationships or have long-standing DM. Telemedicine monitoring should be designed for people who are in need and receptive to telemedicine.
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http://dx.doi.org/10.1089/tmj.2016.0108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359684PMC
March 2017
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