Publications by authors named "Tala Al-Khaled"

10 Publications

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Digital Education in Ophthalmology.

Asia Pac J Ophthalmol (Phila) 2021 Dec 29. Epub 2021 Dec 29.

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, US Singapore Eye Research Institute, Singapore National Eye Centre, Singapore Duke-NUS Medical School, National University Singapore, Singapore National Eye Institute, National Institutes of Health, Bethesda, MD, US.

Abstract: Accessibility to the Internet and computer systems has prompted the gravitation towards digital learning in medicine, including ophthalmology. Using the PubMed database and Google search engine, current initiatives in ophthalmology that serve as alternatives to traditional in-person learning with the purpose of enhancing clinical and surgical training were reviewed. This includes the development of tele-education modules, construction of libraries of clinical and surgical videos, conduction of didactics via video communication, and the implementation of simulators and intelligent tutoring systems into clinical and surgical training programs. In this age of digital communication, teleophthalmology programs, virtual ophthalmological society meetings, and online examinations have become necessary for conducting clinical work and educational training in ophthalmology, especially in light of recent global events that have prevented large gatherings as well as the rural location of various populations. Looking forward, web-based modules and resources, artificial intelligence-based systems, and telemedicine programs will augment current curricula for ophthalmology trainees.
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http://dx.doi.org/10.1097/APO.0000000000000484DOI Listing
December 2021

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

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

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

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

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

Training of Residents and Fellows in Retinopathy of Prematurity Around the World: An International Web-Based Survey.

J Pediatr Ophthalmol Strabismus 2019 Sep;56(5):282-287

Purpose: To characterize retinopathy of prematurity (ROP) training practices in international residency and fellowship programs.

Methods: A publicly available online-based platform (http://www.SurveyMonkey.com) was used to develop a 28-question multiple-choice survey that targeted ROP screening and treatment methods. The authors solicited training programs in the Philippines, Thailand, and Taiwan.

Results: Programs from three countries participated in the survey, and a total of 95 responses collected from residents, fellows, and attending ophthalmologists were analyzed. A descriptive analysis demonstrated that 45 participants (47%) reported 1% to 33% of ROP screenings were performed under direct supervision of attending ophthalmologists, and 35 (37%) reported the use of formal assessments. The majority of participants (Country A: 87%, Country B: 71%, and Country C: 75%) estimated 1% to 33% of their practice was spent screening for ROP. Notably, 44 participants (46%) reported performing zero laser photocoagulation treatments for ROP during training (Country A: 65%, Country B: 38%, and Country C: 38%).

Conclusions: International ophthalmology trainees perform a limited number of ROP examinations and laser interventions. ROP screenings are often unsupervised and lead to no formal evaluation by an attending ophthalmologist. Limited ROP training among ophthalmologists may lead to misdiagnosis and ultimately mismanagement of a patient. Loss of vision and exposure to unwarranted treatments are among the implications of such errors. The findings highlight the need to improve ROP training in international ophthalmology residency and fellowship programs. [J Pediatr Ophthalmol Strabismus. 2019;56(5):282-287.].
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http://dx.doi.org/10.3928/01913913-20190717-01DOI Listing
September 2019

Profile of netarsudil ophthalmic solution and its potential in the treatment of open-angle glaucoma: evidence to date.

Clin Ophthalmol 2018 4;12:1939-1944. Epub 2018 Oct 4.

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

Netarsudil ophthalmic solution is a novel topical intraocular pressure (IOP)-lowering agent that has recently been approved by the US Food and Drug Administration (FDA) for the treatment of ocular hypertension and open-angle glaucoma. Its unique pharmacology allows for IOP lowering as a result of direct reduction in trabecular outflow resistance in addition to a decrease in episcleral venous pressure and aqueous humor production. The efficacy of netarsudil has been shown in animal studies and human clinical trials. It has been shown to be noninferior to the therapy with topical timolol in individuals with baseline IOP <25 mmHg. Importantly, netarsudil has been shown to reduce IOP to the same degree, regardless of baseline levels. There are no known systemic safety issues associated with netarsudil. The most common local adverse effects relate to conjunctival hyperemia. The once-daily dosing schedule is advantageous for individuals who have difficulties with medication adherence. Further studies of a combination of netarsudil and latanoprost agents are currently underway.
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http://dx.doi.org/10.2147/OPTH.S154001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6177382PMC
October 2018
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